UC  SOUTHERN  REGIONAL  LIBRARY  FACILITY 


G     000  005  489     o 


^liC.^ 


K^^'^?^^-, 


->^i^;r-. 


.^.^_ 


^&:'$' 


-■■:**  ■  i 


i^v^*^;';' 


■-'?>■>''-.' 


r&^ 


5950 


THE  LIBRARY 
OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 

GIFT  OF 

SAN  FRANCISCO 
COUNTY  MEDICAL  SOCIETY 


I 


^ 


THE 


HEALING  OF  ARTERIES 


AFTER    LIGATURE 


IN    MAN    AND   ANIMALS 


BY 


J.    COLLINS   WARREN,    M.  D., 

ASSISTANT     PROFESSOR     OF    SLRGERY,     HARVARD     IMVERSITV.        SURGEON    TO    THE     MASSACHUSETTS 

GENERAL   HOSPITAL.      MEMBER   AMERICAN   SURGICAL   ASSOCIATION.      HONORARY 

FELLOW    PHILADELPHIA    ACADEMY    OF   SURGERY. 


NEW  YORK 
WILLIAM  WOOD  &  COMPANY 
1886 


Copyright,  1886, 
WILLIAM   WOOD   &   COMPANY 


The  Publishers 

Book  Composition  and  Electrotvping  Co. 

157  AND  159  William  St.,  New  York. 


liiosredical 
Library 

510 

my 


Was  die  Erfindung  der  Buchdruckerkunst  fur  die  Wiss- 
enschaft,  was  die  Erfindung  des  Schiesspulvers  fiir  den 
Krieg,  was  die  Erfindung  der  Eisenbahn  fiir  den  Verkehr 
der  Vulker  untereinander,  das  ist  die  Erfindung  der  Arte- 
rienunterbindung  fiir  die  Chirurgie. 

DiFFENBACH,  Dif  Operative  Chirurgie, 
Leipzig,  1S45,  i.,  121. 


PREFACE. 


The  study  of  the  subject  of  whith  this  monograph  treats,  has 
been  carried  on,  hitherto,  in  a  more  or  less  fragmentary  way,  different 
portions  of  it  having  received  very  minute  attention,  and  from  the 
hands  of  the  ablest  pathologists.  The  attempt  has  been  made  here 
to  study  the  question  from  a  more  comprehensive  standpoint,  to  ob- 
serve not  only  the  behavior  of  the  various  tissues  concerned  in  the 
process  of  repair,  but  also  the  different  phases  through  which  the 
vessel  passes  from  the  moment  of  ligature  until  the  condition  is 
reached  after  which  no  further  change  occurs. 

The  investigations  have,  for  the  most  part,  been  carried  on  in  the 
Harvard  Medical  School,  and  the  writer  takes  this  opportunity  to  ex- 
press his  appreciation  of  the  great  facilities  offered  for  such  work  in 
the  Physiological  and  Pathological  Laboratories. 

Experiments  were  performed  also  in  the  Veterinary  Department 
of  the  University,  with  the  permission  of  Professor  C.  P.  Lyman. 

Through  the  courtesy  of  Dr.  J.  S.  Billings,  the  very  valuable  col- 
lection of  arteries  in  the  Army  Medical  Museum,  at  Washington, 
was  placed  at  the  writer's  disposal  for  study. 

Finally  the  writer  wishes  to  express  his  indebtedness  to  Dr.  H. 
P.  Quincy  for  skilled  assistance  in  many  of  his  experiments. 

Boston,  March,  1886. 


CONTENTS. 


PAGE 

History,         ..........         i 

II. 

Experiments  on  Animals,     .......       47 

III. 
Human  Subject,   .........       82 

IV. 

Closure  of  the  Fcetal  Vessels,  .         .         .         .         .         .111 

V. 
Summary,       ........  138 


Appendix,      .         .         .         .         .         .         .         .         .         .     i53 

Bibliography,        .         .         .         .         .         .         .         .         .163 

Index,  .......•■•      ^7^ 


The  Ligature  of  Arteries. 


CHAPTER  I. 

HISTORY. 


LiSFRANC  well  says:  "  La  ligature  a  ete  *  *  *  I'objet  de 
recherches  si  multipliees  que  I'histoire  des  diverses  precedes  des 
experiences  tentees  pour  connaitre  la  maniere  d'agir  des  instruments 
inventes  pour  la  faciliter  ou  1'  ameliorer  pourrait  fournir  matiere  a 
plusieurs  volumes."  It  needs  but  a  casual  glance  at  the  literature 
of  this  important  department  of  surgery  to  discover  that  the  ligature 
was  employed  by  surgeons  in  early  historic  times. 

Probably  the  first  recorded  use  of  a  ligature  is  that  mentioned  by 
Siisrutas  '  1500  B.C.,  who  employed  it  in  tying  the  umbilical  cord: 
no  mention,  however,  is  made  by  him  of  its  use  in  surger)^  nor  do 
we  find  any  in  the  writings  of  the  early  Egyptians,  from  whom  the 
Greek  writers  of  that  time  obtained  their  knowledge  of  surgery.  Had 
the  ligature  been  in  use  at  that  time  we  should  have  undoubted  evi- 
dence thereof  in  the  writings  of  Hippocrates- (460-375  B.C.).  By 
some  writers  he  has  indeed  been  regarded  as  the  discoverer  of'the 
ligature.  The  passage  upon  which  this  claim  is  based  is  the  follow- 
ing: "  Sanguinem  e  venis  profluentum  sistunt  animi  deliquium, 
figura  aliorsum  tendens  venae  interceptio,  linamentum  contortum 
appositio  deligatio." 

This  rendering  of  the  Greek  text  is  not  accepted  by  some  of  the 
best  authorities,  and  the  sixth  book,  in  which  it  occurs,  is  regarded 
by  many  as  not  genuine.* 

Praxagoras    (335    b.c.)   first  discovered    the  difference  between 

*  Both  Haeser  '56  and  Greifenberger  state  emphatically  that  no  traces  of  the 
mention  of  the  ligature  are  to  be  found  in  the  writings  of  the  Hippocratic  school. 
In  Adams'  "  Genuine  Works  of  Hippocrates,"  there  is  no  allusion  to  it. 

I 


2  TJlc  Ligature  of  Arteries. 

arteries  and  veins,  and  his  pupil,  Herophilus,  and  a  colleague,  Era- 
sistratus,  first  bound  limbs  previous  to  amputation,  to  prevent  hemor- 
rhage. 

It  is  probable  that  the  ligature  was  first  introduced  by  some  sur- 
geon of  the  Alexandrian  school,  in  which  great  progress  was  made 
in  the  study  of  anatomy  and  surgery;  for  Celsus,^  (25-30  B.C.  45-50 
A.D.  )  who  was  deeply  versed  in  the  literature  of  his  time,  and  par- 
ticularly that  of  Alexandria,  derived  his  knowledge  of  the  ligature 
from  this  School. 

Aulus  (or  Aurelius  Cornelius)  Celsus  was  one  of  the  first  Roman 
medical'authors.  The  following  quotation  from  his  works  gives  a 
fair  idea  of  the  means  used  to  arrest  hemorrhage  at  that  day. 

"  If  the  hemorrhage  be  alarming,  which  may  be  known  by  the  sit- 
uation and  size  of  the  wound,  and  from  the  violence  of  the  bleeding, 
the  wound  is  to  be  filled  with  dry  lint,  and  a  sponge  squeezed  from 
cold  water  is  to  be  pressed  firmly  on  it  by  the  hand.  If  the  bleeding 
does  not  subside  by  these  means,  the  pledgets  are  to  be  frequently 
changed,  and  if  not  sufficiently  powerful  whilst  dry,  they  are  to  be 
moistened  with  vinegar.  This  last  is  a  powerful  agent  for  suppress- 
ing hemorrhage;  and,  on  that  account,  some  pour  it  into  the  wound; 
but  here  again  it  is  to  be  feared  that  the  matter,  by  being  powerfully 
retained  there,  may  subsequently  produce  high  inflammation.  It  is 
this  which  prevents  one  using  corrosives,  or  those  applications  which, 
by  their  caustic  quality,  induce  an  eschar;  although  most  of  them 
check  hemorrhage.  However,  if  once  in  a  way  we  do  have  recourse 
to  such,  the  mildest  are  preferable.  But  should  these  means  fail 
also,  the  bleeding  vessels  should  be  taken  up,  and,  ligatures  having 
been  applied  above  and  below  the  wounded  part,  the  vessels  are  to 
be  divided  in  the  interspace;  that  thus  they  may  retract  while  their 
orifices  remain  closed.  When  the  case  does  not  admit  of  this  meas- 
ure, the  vessels  should  be  cauterized.'^ 

It  is  supposed  that  the  following  passage  from  the  writings  of 
Celsus  indicates  that  linen  thread  was  the  material  used;  "Qua 
parte  vero  inhaerebunt  et  ab  superiore  et  ab  inferiore  parte  lino  vin- 
ciendae,  etc."  The  manner  of  applying  the  ligature  is  thus  described: 
"  But,  before  excision,  these  at  their  extremities  ought  to  be  tied 
with  a  thread,  its  ends  being  left  out  of  the  wound,  like  as  in  other 
veins  requiring  ligature." 

In  amputations,  the  ligature  does  not  appear  to  have  been  used, 
probably  because  Celsus  was  not  familiar  with  the  anatomy  of  arte- 
ries.   When  these  vessels,  after  being  severed,  had  retracted  beneath 


History.  3 

the  surface  of  the  wound,  he  did  not  attempt  to  find  them  and  tie 
them. 

The  successors  of  Celsus  say  little  about  the  ligature,  a  circum- 
stance supposed  to  be  due  to  the  fact  that  they  did  not  think  it  nec- 
essary to  mention  this  detail  of  an  operation.*  It  is  doubtful  if  the 
ligature  were  much  used.  Amputation  was  avoided  as  much  as  pos- 
sible. 

Archigenes,5  however,  who  flourished  about  the  end  of  the  first 
century  of  the  Christian  Era,  made  such  modifications  in  the  meth- 
ods of  amputation  that  he  was  able  to  resort  to  it  much  more  freely 
than  other  surgeons  of  his  time.  He  controlled  bleeding  by  band- 
ages placed  around  the  limb,  applied  provisional  ligatures  to  large 
vessels,  and  tied  others  after  the  limb  had  been  removed. 

Rufus  of  Ephesus  recognized  the  difference  between  arteries  and 
veins.  Both  he  and  Heliodbrus,  a  colleague  of  Archigenes,  were 
familiar  with  torsion,  as  is  shown  in  the  following  quotation  from 
Rufus:  "  Vas  immissa  volsella  extendemus  et  moderate  circumflec- 
temus,  at  ubi  ne  sic  quidem  cessaverit  (hemorrhagia)  vinculo  con- 
stringemus." 

Heliodorus^  says  in  a  description  of  an  operation  for  the  radical 
cure  of  hernia,  "  After  laying  bare  the  tunica  dartos,  the  larger  ves- 
sels should  be  tied;  the  smaller  ones  should  be  transfixed  with  a 
hook  twisted  round  several  times,  and  by  means  of  the  twisting 
closed." 

Claudius  Galenus'  (1 31-2 11  a.d.)  makes  mention  of  the  liga- 
ture in  many  parts  of  his  works.  He  was,  however,  not  a  practical 
surgeon,  and  avoided  the  use  of  the  knife.  According  to  some 
authorities  his  imperfect  knowledge  of  the  vessels  led  him  to  recom- 
mend tying  the  central  end  of  the  vessel  only.  According  to  Adams 
he  advises  an  accurate  examination  of  every  deep-seated  vessel  to 
ascertain  whether  it  is  an  artery  or  a  vein,  "  after  which  it  is  to  be 
seized  with  a  hook,  and  twisted  moderately.  If  the  flow  of  blood  is 
not  stopped  thereby,  he  recommends  us,  if  the  vessel  is  a  vein,  to 
endeavor  to  restrain  it  without  a  ligature  by  the  use  of  styptics,  or 
things  of  an  obstruent  nature,  such  as  roasted  rosin,  the  fine  down 
of  wheaten  flour,  gypsum,  and  the  like.     Byt,  if  the  vessel  is  an 


*  Haeser  quotes  a  passage  from  Paulus  .^{gineta  in  support  of  this  view  which 
he  renders  thus:  "Having  first  secured,  of  course,  (wie  natiirlich,  uf  f!/fOf)  the 
vessels."  The  same  passage  is,  however,  rendered  by  Adams:  "  Securing,  as  is 
proper,  with  a  thread,  any  vessel  that  may  come  in  the  way." 


4  TJlc  Ligature  of  Arteries. 

artery,  he  says  one  of  two  things  must  be  done,  either  a  ligature  must 
be  apphed  to  it,  or  it  must  be  cut  across.  He  adds,  we  are  even 
obliged  sometimes  to  apply  a  ligature  to  large  veins  and  cut  them 
across."  He  used  silk  thread  and  thread  of  Celtic  linen,  and  also  gut, 
not  in  the  Lister  sense,  but  simply  for  the  purpose  of  securing  a  durable 
material;  he  even  mentions  the  place  where  he  obtained  his  ligatures, 
"  The  shop  on  the  Via  Sacra  between  the  temple  Roma  and  the 
Forum."  In  this  connection  the  fact  is  interesting  that  in  the  Na- 
ples Museum,  are  to  be  seen  a  pair  of  sliding  forceps  found  at  Pom- 
peii, which  were  evidently  intended  to  be  used  with  the  ligature. 
Galen  was  afraid  that  an  aneurism  might  develop  if  the  ligature  did 
not  come  away  before  the  wound  was  closed  by  new  growth.  He 
thought  that  the  vessels  were  healed  by  a  growth  from  the  surround- 
ing tissues;  "quae  namque  caro  in  abscisis  vasorum  partibus  coal- 
escit,  ea  pro  operculo  est  ac  osculum  eorum  claudit." 

Antyllus,  at  the  end  of  the  third  century,  not  only  invented  an 
operation  for  the  cure  of  aneurism  which,  with  slight  modification 
still  bears  his  name;  but  he  also  speaks  of  the  same  method  of 
dealing  with  vessels  in  removing  tumors.  He  says:  "  If  the  vessel 
cannot  be  pushed  aside,  it  should  be  tied  on  both  sides  of  the  wound 
and  cut  through;  if  the  tumor  were  under  the  carotid  or  jugular  it 
would  be  unsafe  to  try  this  method,  as  it  might  produce  instant 
death." 

Among  the  latest  of  the  Greek  writers  are  Aetius^  (502-575),  and 
Paulus  ^gineta^  (625-690);  the  latter  mentions  the  ligature  more 
frequently  than  any  other  ancient  writer.  "When  the  bleeding  is 
stopped,"  he  says,  "endeavor,  if  it  is  a  vein>  to  restrain  the  blood 
without  a  ligature  by  the  same  medicine;  but  if  it  is  an  artery  one  of 
two  things  must  be  done, —  either  apply  a  ligature  around  it  or  cut 
the  vessel  asunder,  by  which  means  you  will  restrain  the  blood. 
Sometimes  too  we  are  obliged  to  apply  a  ligature  to  large  veins,  and 
also  occasionally  to  cut  them  asunder  transversely.  *  *  *  You 
may  know  whether  it  is  a  vein  or  an  artery  that  pours  forth  the  blood, 
from  this:  that  the  blood  of  an  artery  is  brighter  and  thinner,  and  is 
evacuated  by  pulsation,  whereas  that  of  the  vein  is  blacker  and  with- 
out pulsation."  The  following  passage  has  special  significance, 
showing  that  the  ligature  was  not  confined  to  small  vessels  before 
the  time  of  Pare.  "But  if  the  weapon  has  lodged  in  any  of  the 
larger  vessels,  such  as  the  internal  jugular  or  carotid  and  the  large 
arteries  in  the  armpits  or  groins,  and  if  the  extraction  threaten  a 
great  hemorrhage,  they  are  first  to  be  secured  with  ligatures  on  both 


History.  5 

sides,  and  then  the  extraction  is  to  be  made."  This  practice  was, 
however,  limited  to  the  class  of  injuries  mentioned,  and  rarely  ex- 
tended to  amputation  and  other  surgical  operations.  Torsion  is  not 
mentioned  by  Paulus,  although  it  was  in  use  in  the  time  of  Oribasus 
(326-403)  who,  in  a  quotation  from  Heliodorus,  describing  the  radi- 
cal cure  of  hernia,  states  that  after  laying  bare  the  tunica  dartos,  the 
larger  vessels  are  to  be  tied,  the  small  ones  to  be  seized  with  a  hook, 
and  twisted  round  several  times,  and  by  this  means  closed.  It  is 
probable  that,  in  later  times,  the  more  frequent  use  of  the  actual 
cautery  displaced  this  method. 

The  Arabian  physicians  who  transmitted  the  writings  of  these 
authors  to  the  Italian  and  French  surgeons,  although  they  mentioned 
the  ligature,  rarely  used  it,  confining  themselves  almost  entirely  to 
the  actual  cautery.  During  the  period  at  which  this  school  flour- 
ished, little  or  nothing  was  'done  for  the  advancement  of  surgery. 
This  was  due  to  the  insufferable  prejudices  of  that  time:  religion 
forbade  the  study  of  anatomy,  and  the  medical  man  regarded  it  as 
a  disgrace  to  be  employed  in  any  manual  labor,  and  contented  him- 
self with  writing  prescriptions,  leaving  the  use  of  the  cautery  and  the 
knife  to  subordinates.  Avenzohar'^  (1113-1162)  says:  "  Omnia  hace 
ad  dictos  servitores  medicorum  habent  pertinere  ad  medicum  autem 
honoratum  nihil  aliud  pertinere  dicimus  nisi  ut  consilium  praestet 
solummodo  ciborum  medicinarumque  infirmi  absque  aliqua  opera- 
tione  manuum  quemadmodum  non  convenit  ei  facere  sirupos  et 
electuaria  suis  manibus." 

Avicenna"  (980-1037)  also  says  of  amputations  of  the  arm  and 
thigh,  "  et  medicus  debet  ab  eo  fugere."  Rhazes  (850-922)  used 
linen  thread  ligatures,  and  recommends  them  for  large  vessels,  but 
he  generally  advises  the  more  fashionable  styptic  and  cautery.  Avi- 
cenna  has  but  little  to  say  about  the  ligature,  which  he  confines  to 
arteries  alone. 

Albucasis  or  Abulcasis '•*  (1106),  the  most  prominent  man  of  this 
school,  was  more  familiar  with  the  writings  of  Paulus  ^gineta,  and 
used  the  ligature  more  freely,  although  he  devoted  a  whole  book  to 
the  cautery.  He  thus  describes  the  ligature:  "  At  sin  arteria  magna 
sit  oportet  illam  in  duobis  locis  ligare  cum  filo  duplicato  forti,  sit 
vero  filum  ex  serico  vel  ex  testudinis  chordis  ne  festinet  illis  corrup- 
tio  antequam  vulnus  consolidetur,  accideret  enim  hemorrhagia. 
Tum  amputa,  quod  superfluum  est,  inter  duas  ligaturas."  Before  re- 
moving tumors  he  tied  the  large  vessels,  excising  the  growth  a  day 
or  two  later.     He  performed  the  operation  of  Antyllus  for  aneurism. 


6  TJic  Ligature  of  Arteries. 

Neither  Avenzohar,  nor  his  pupil,  Averroes,'^  the  later  representa- 
tives of  the  Arabian  school,  has  much  to  say  about  the  ligature. 

The  Italian  school  naturally  suffered  from  the  influence  of  its 
predecessor:  medical  literature  was  studied  only  by  the  clergy,  and 
the  religious  prejudices  of  that  time  presented  the  same  obstacles  to 
the  advance  of  surgical  science  that  it  had  to  the  Arabian  school. 
The  chief  improvement  was  the  introduction  of  the  mediate  ligature 
applied  with  a  needle,  like  a  stitch,  by  Roger  of  Parma  (1214),  as 
recorded  by  his  pupil  Roland;  and  his  example  was  followed  by 
almost  all  other  Italian  surgeons.  Bruno  (1252),  gives  the  advice, 
when  other  means  fail,  to  seize  the  artery  with  a  hook,  and  lift  it  up 
before  passing  the  ligature.  In  Lanfranchi's  Surgery,"^  which  was 
written  in  the  middle  of  the  tenth  century,  occurs  the  following  pas- 
sage: "  Oportet  te  tunc  aut  venam  ligare  et  ipsam  de  loco  extrahere 
et  caput  venae  vel  arterije  contorquere  aut  ferro  candente  sanguinem 
sistere, "showing  that  the  old  teaching  had  not  been  wholly  forgot- 
ten. Guy  de  Chauliac,''  his  pupil,  followed  Galen's  advice  to  ai)ply 
the  ligature  to  the  central  end  of  the  vessel  when  other  means  failed, 
a  custom  which  most  of  the  Italian  surgeons  followed.  Silk  was  the 
material  used  by  de  Chauliac. 

With  the  study  of  anatomy,  which  was  revived  towards  the 
close  of  the  middle  ages,  surgery  made  its  first  modern  ad- 
vances; but  the  ligature  was  still  chiefly  confined  to  cases  of  in- 
jury where  large  vessels  were  implicated.  Among  the  principal 
changes  introduced  at  this  time  was  the  transfixion  of  the  vessel 
by  a  needle  armed  with  a  double  ligature  by  Bertaplagia,  '^'  a 
Paduan  professor,  who  flourished  about  the  middle  of  the  fifteenth 
century.  Giovanni  Vigo  has  been  accredited  by  some  with  the  dis- 
covery of  acupressure  on  the  strength  of  the  following  passage: 
"modus  ligationis  aliquando  efficitur  intromittendo  acum  sub  vena 
desuper  filum  strigendo."  A  process  somewhat  similar  to  acupressure 
we  first  find  mentioned  about  this  time  by  Mariano  Santo,-'  a  traveling 
Italian  surgeon,  who  passed  a  deep  stitch  through  the  flap  of  a 
wound  including  the  end  of  the  vessel.  In  Naples,  Alfonzo  Ferri  -^ 
used  a  sickle-shaped  needle,  with  blunt  edges,  armed  with  a  double 
ligature;  Angelo  Bolognini,''" founder  of  the  school  of  Bologna,  used 
silk  ligatures,  but  only  to  a  limited  extent.  The  cautery  and  styp- 
tics still  retained  their  hold  as  popular  methods,  and  were  largely 
employed.  After  the  impetus  given  to  surgery  in  France  by  the 
arrival  of  Lanfranchi  in  Paris  in  1295,  and  by  his  pupil  Guy  de  Chau- 
liac, little  progress  was   made  in  that  country.     Among  those  who 


History.  j 

were  the  immediate  predecessors  of  Pare  were  Jacques  Houllier,  wlio 
used  both  the  hook  and  the  forceps,  but  timidly;  and  Jean  Tagault, 
who  was  professor  both  in  Paris  and  Bologna,  and  followed  the  teach- 
ings of  Chauliac.  In  Germany  at  this  period  the  ligature  was  known 
to  Braunschweig,  "  the  Senior  of  German  surgery,"  to  Gersdorf  and 
to  Ryff. 

When  Ambroise  Pare  -■•  began  to  practice  surgery  the  ligature  had 
been  in  use  for  nearly  two  thousand  years,  but  its  range  in  surgery, 
it  will  be  seen,  was  extremely  limited.  Large  vessels  were  tied  only 
when  severe  injuries  forced  the  surgeon  to  resort  to  the  ligature, 
and  in  surgical  operations  it  was  confined  chiefly  to  vessels  of  mode- 
rate calibre.  The  few  instances  recorded  by  the  ancients  of  its  use 
in  amputations  appear  to  have  been  forgotten,  and  the  primitive 
methods  employed  at  that  time  for  removing  limbs  have  been  justly 
declared  to  be  more  worthy  of- the  butcher  than  of  the  surgeon.  This 
great  surgeon  is,  therefore,  entitled  to  the  credit  of  not  only  appre- 
ciating fully  this  method  of  arresting  hemorrhage,  but  of  making  the 
ligature  universally  applicable.  To  him  this  contribution  to  surgery, 
which  occurred  in  1552,  naturally  appeared  in  the  light  of  a  discov- 
ery original  with  himself,  for,  with  isolated  exceptions,  the  fashion 
of  the  day  undoubtedly  differed  little  from  that  in  vogue  a  thousand 
years  before.  In  the  English  translation  of  his  works  occurs  the  fol- 
lowing passage:  "Therefore,  I  would  earnestly  entreat  all  chirurgeons, 
that  leaving  this  old  and  too,  too  cruel  way  of  healing,  they  would 
embrace  this  new,  which  I  think  was  taught  me  by  the  special  favor 
of  the  sacred  Deity:  for  I  learnt  it  not  of  my  masters,  nor  of  any 
other:  neither  have  I  at  any  time  found  it  used  by  any:  only  I  have 
read  in  Galen  that  there  was  no  speedier  remedy  for  staunching  of 
blood  than  to  bind  the  vessels  toward  their  roots;  to  wit,  the  Liver 
and  the  Heart."  Pare  did  not  attempt  to  isolate  the  vessel  but  re- 
sorted to  the  mediate  ligature.  He  says:  "II  te  ne  faut  estre  trop 
curieux  de  ne  pinser  seulement  que  les  dits  vaisseaux:  pource 
qu'il  n'y  a  danger  de  prendre  avec  eux  quelque  portion  de  la  chair 
des  muscles,  ou  autres  parties:  car  de  ce  ne  pent  aduenir  aucun 
accident:  ainsi  avec  ce  I'union  des  vaisseaux  se  fera  mieux  et  plus 
surement,  que  s'il  n'y  auoit  seulement  que  le  corps  des  dits  vaisseaux 
compris  en  la  ligature.  Ainsi  tires  on  les  doit  bien  lier  avec  bon  fil 
qui  soit  en  double."  He  sometimes  passed  the  ligature  arounil  the 
vessel  by  means  of  a  needle,  and  he  also  used  the  forceps.  Occa- 
sionally the  needle  and  thread  were  passed  through  the  flap,  the  skin 
being  protected  by  a  compress,  over  which  the  knot  was  tied.      He 


8  The  Ligature  of  Arteries. 

used  both  single  and  double  ligatures:  his  successors  generally  used 
several.  He  adopted  the  view  of  Galen,  that  the  granulations  closed 
the  mouth  of  the  vessel. 

In  spite  of  the  support  given  to  this  method  by  so  great  an  author- 
ity, the  example  of  Pare  found  but  few  imitators.  Even  Guillemeau  ^s 
who  was  the  champion  of  his  friend  and  teacher,  and  was  suffi- 
ciently interested  in  the  operation  to  invent  a  new  forceps,  confined 
the  use  of  the  ligature  to  primary  amputations,  and  used  cautery  in 
case  of  gangrene. 

Harvey's  discovery,  which  occurred  in  1619,  gave  but  a  feeble 
impetus  to  the  ligature.  Richard  Wiseman,-^  who  has  been  called 
the  "Father  of  English  Surgery,"  and  the  "English  Pare,"  made 
experiments  for  staunching  the  blood  of  arteries  and  veins.  He 
preferred  the  use  of  a  "royal  styptic,"  or  the  cautery.  Cooke,  of 
Warwick,  refers  in  1675  to  Pare  for  a  description  of  the  method  of 
"stitching"  the  vessels;  and  adds  that  it  "is  almost  wholly  re- 
jected." Fabricius  Hildanus,^  in  Germany,  favored  the  ligature, 
but  after  him  there  was  a  decadence  of  surgery  in  that  country, 
and  the  ligature  was  rarely  used.  Cornelius  A"an  Soligen^"^  modified 
the  forceps  so  that  the  jaws  remained  closed  after  seizing  the  artery; 
but  although  he  and  his  colleagues  were  familiar  with  the  ligature, 
and  performed  Antyllus's  operation  for  aneurism,  there  was  little 
progress  to  record.  Fallopio,  in  1660,  described  the  operation 
accurately.  He  recommended  that  the  nerves  and  arteries  should  be 
carefully  separated  with  the  finger  nail,  and  asserted  that  the  sheath 
need  not  be  opened,  as  it  causes  but  little  pain  to  include  it  in  the 
ligature.  He  observed  the  return  of  the  circulation  in  a  limb  one 
year  after  ligature  of  the  popliteal,  but  thought  it  took  place  in  the 
ligatured  vessel.  Marcus  Aurelius  Severinus  (1580-1656)  was  the 
first  to  tie  the  femoral  artery  at  Poupart's  ligament.  Gaspare  Taga- 
liacozzi  (Taliacotius)  still  depended,  in  his  rhinoplastic  operations, 
however,  upon  cautery  and  styptics. 

In  spite  of  the  invention  of  the  tourniquet  by  Morel  ='  in  1674, 
and  of  the  aneurism  needle  by  Barthelemy  Saviard^'  (1656-1704), 
(a  blunt  needle,  "  fait  expres  pour  faire  la  ligature  des  arteres  "), 
the  imperfect  knowledge  of  anatomy  and  of  the  physiology  of  the 
circulation  prevented  surgeons  of  that  day  from  appreciating  the 
advantages  of  the  ligature,  and,  at  the  opening  of  the  eighteenth 
century,  the  actual  cautery  was  still  the  customary  method  of  arrest- 
ing hemorrhage  at  the  Hotel  Dieu.  The  contrast  between  the  liga- 
ture and  the  cautery  was  not  found  to  be  so  great  as  might  have 


History.  9 

been  supposed.  A  glance  at  Fare's  plates  shows  the  forceps,  an  in- 
strument of  rude  and  clumsy  pattern;  and  it  is  not  surprising  to 
learn  that  the  new  method  was  dreaded  by  some  more  than  the 
cautery.  No  attempt  was  made  to  isolate  the  vessel,  but  veins,  nerves, 
and  arteries  were  indiscriminately  bound  together  by  the  "  mediate  " 
method.  No  wonder  that  patients  complained  of  great  pain,  with 
cramps  and  twitchings,  in  the  stump.  And  even  Petit,  with  whom 
modern  investigations  on  the  healing  of  arteries  may  be  said  to  have 
begun,  (1731),  actually  proposed  compression  as  a  substitute  for  the 
ligature. 

Sharp, 3^  in  his  "  Critical  Enquiry  into  the  Present  State  of  Sur- 
gery in  England  "  about  this  time,  states  that  the  ligature  was  used 
sparingly  from  a  "  horrid  apprehension  of  compressing  the  nerves." 
But  Alexander  Munro  =^  soon  showed  the  advantages  of  the  direct 
ligature,  and  that  it  could  be  applied  without  danger  to  the  vessel, 
as  did  also  Pierre  Dionis  3-  in  France,  at  the  beginning  of  the  eigh- 
teenth century.  The  latter  used  chiefly  the  ligature  "en  masse," 
and  introduced  a  sliding  forceps,  the  "Valet  a  Patin,"  but  he  only 
tied  the  central  end  of  a  vessel. 

Petit  3s  first  called  attention  to  the  agency  of  the  thrombus  in 
checking  hemorrhage;  the  blood  efCused  around  the  end  of  the 
vessel  he  termed  the  "couvercle":  that  found  within  the  lumen 
he  named  the  "bouchon."  Its  protective  action  he  showed  was 
only  provisional,  but  it  remained  for  some  time  closely  adherent 
to  the  internal  wall,  and  eventually  disappeared  when  permanent 
cicatrization  took  place.  A  few  years  later,  Morand^?  confirmed 
these  views  upon  the  formation  of  the  thrombus,  but  dwelt  par- 
ticularly upon  the  retraction  and  contraction  of  the  divided  walls; 
he  also  showed  that  the  inner  walls  were  ruptured  by  the  ligature 
and  inverted;  and  that  the  thrombus  was  thus  enabled  to  withstand 
the  blood  pressure.  It  was  probably  only  in  exceptional  cases  that 
either  factor  could  operate  without  the  aid  of  the  other  in  preventing 
further  hemorrhage.  He  attributed  therefore  more  importance  to 
the  ligature  than  did  Petit.  Pouteau  '•'■  of  Lyons,  in  1 760,  denied 
the  constant  presence  of  a  coagulum,  and  maintained  that  the  re- 
traction of  the  artery  had  not  yet  been  satisfactorily  demonstrated. 
He  thought  that  the  clot  was  only  a  weak  and  subsidiary  means,  and 
that  the  swelling  of  the  cellular  tissue  around  the  extremity  of  the 
vessel  ofTered  the  chief  obstruction  to  the  bleeding.  He  therefore 
advised  that  as  much  tissue  as  possible  should  be  included  in  the 
ligature:  but  the  pain  caused  by  this  clumsy  method  made  the  actual 


lo  The  Ligature  of  Arteries. 

cautery  seem  mild  hy  comparison.  A  general  protest  was  soon 
raised  by  French,  English,  and  German  surgeons  against  this 
method,  and  it  was  shown  that  it  might  even  prove  a  source  of 
secondary  hemorrhage.  Pouteau,  in  describing  the  thrombus,  says, 
"  Ce  corps  conique  degorge  dans  de  I'eau  claire,  parut  tres  distincte- 
ment  un  sac  quasi  membraneux  en  forme  d'entonnoir  lorgne,  rempli 
d'un  caillot  de  sang  noiratre:  il  laissoit  voir  a  la  loupe  une  grande 
quantite  de  bourgeons,  semblable  a  ceux  qui  naissent  d'une  plaie 
qui  commence  a  s'incarner."  It  is  not  probable  that  these  were 
true  granulations,  as  this  was  but  the  third  day  of  the  healing  pro- 
cess. 

In  England  little  value  was  attributed  to  the  efficac}^  of  the  throm- 
bus. Kirkland,-'-  with  whom  other  English  writers  agreed,  regarded 
the  contraction  of  the  arteries  rather  than  the  coagulation  of  the 
blood,  as  nature's  means  of  arresting  bleeding.  He  cites  those  cases 
where  a  sudden  stoppage  of  hemorrhage  follows  fainting,  and  the 
action  of  the  umbilical  vessels  in  the  newly  born  infant.  The  vessel 
is  closely  contracted  for  an  inch  or  more  from  its  extremity;  the  sides 
become  adherent,  and  it  subsequently  shrinks  into  a  cord.  Gooch,'*^ 
who  was  the  first  apparently  to  expound  these  views,  points  out  that, 
after  contraction  and  retraction,  the  walls  of  the  vessels  coalesce 
as  far  as  the  first  branch,  and  their  mouths  are  closed  by  a  growth 
of  tissue  aided  by  the  vasa  vasorum.  White ''^  even  maintained 
that  the  clot  prevented  closure  of  the  artery,  and  that  it  should 
be  removed.  In  John  Bell's  opinion  the  pressure  exerted  by  the 
surrounding  tissue  infiltrated  with  blood  was  sufficient  to  prevent 
hemorrhage,  adhesive  inflammation  subsequently  uniting  the  vessel 
walls.  Hunter -t^  gave  an  impetus  to  the  study  of  this  question  by 
his  novel  views  on  the  process  of  healing  by  first  intention.  Blood 
being  effused  between  the  lips  of  the  wound,  the  red  corpuscles  were 
absorbed,  and  the  coagulated  lymph  was  transformed  into  the  new 
cicatricial  tissue.  He  found  that  spaces  could  be  filled  with  an  in- 
jection mass  coming  from  the  lumen  of  the  vessel,  and  thought  that, 
like  similar  appearances  in  inflamed  surfaces,  and  the  vascular  loops 
in  the  embryo  of  the  chick,  they  were  the  beginning  of  a  new  vascu- 
lar development.  It  is  evident  that  he  believed  in  the  so-called 
"organization  of  the  thrombus;"  but  he  also  believed  in  the  agency 
of  the  vessel-walls,  for  he  says:  "Arteries  unite  by  adhesion  when 
their  sides  are  compressed:  this  we  find  after  the  division  of  the 
larger  arteries  after  amputation."  The  effects  of  rupturing  an  artery 
by  tearing  or  pulling  were  recognized  by  him.     "  It  is  the  property 


History.  1 1 

of  flexible  bodies  to  have  tlieir  diameters  contracted  as  they  are 
lengthened:  in  arteries  this  might  be  carried  to  a  great  degree  when 
permanent  effects  are  to  be  produced.  *  *  *  Surgeons  do  not 
take  advantage  of  this,  but  farriers  and  gelders  do."  He  thought 
that  arteries  of  considerable  size  were  sometimes  regenerated.  A 
portion  of  the  carotid  artery  of  a  young  ram  being  removed,  the  cir- 
culation was  re-established  in  twenty-seven  days;  and  in  another  case 
in  eigiit  weeks.  He  explained  the  regenerative  process  in  this  way: 
— small  vessels  are  seen  in  the  coagulated  lymph  thrown  out,  and 
connecting  the  ends  of  the  vessel:  one  of  these  enlarges  and  the 
others  atrophy,  and  the  circulation  in  the  vessel  is  thus  restored. 

Closely  following  upon  Hunter's  came  the  observations  of 
Jones.,"  whose  extensive  experiments  and  thorough  and  painstak- 
ing work  have  made  him  the  chief  authority  upon  this  subject  pre- 
vious to  the  era  of  histological  research.  To  this  author  is  due  the 
credit  of  clearing  up  the  existing  confusion.  He  attributed  to  the 
different  structures  concerned  in  the  healing  process  their  relative 
importance.  His  descriptions  are  so  much  more  true  to  nature 
than  those  commonly  found  in  text  books  of  the  present  day  that 
they  deserve  more  than  a  passing  reference.  His  first  series  of  ex- 
periments, chiefly  on  horses,  was  undertaken  to  illustrate  nature's 
means  of  arresting  hemorrhage.  An  artery  was  divided,  and  the 
external  wound  quickly  closed  so  as  to  make  the  division  as  nearly 
subcutaneous  as  possible.  The  artery  was  found  retracted  in  its 
sheath  and  slightly  contracted  at  its  extremity.  A  coagulum  was  found 
within  the  sheath  and  external  to  the  vessel,  appearing  like  a  con- 
tinuation of  the  artery;  and,  later,  a  slender  conical  coagulum  within 
the  vessel  only  partially  adherent.  Permanent  occlusion,  he  says, 
was  effected  by  the  inflammation  of  the  walls,  the  vasa  vasorum,  pour- 
ing out  lymph  which  collects  between  the  two  coagula,  is  somewhat 
intermingled  with  them,  and  is  firmly  united  all  round  to  the  inter- 
nal coat.  The  external  clot  is  soon  al^sorbed,  as  is  also,  later,  the 
coagulated  lymph  which  has  produced  a  thickened  and  almost  car- 
tilaginous appearance  in  the  parts  around  the  vessel.  In  the  mean- 
time the  vessel  is  contracted  up  to  the  first  branch:  its  cavity  is 
obliterated,  and  its  condensed  tunics  are  reduced  to  a  delicate  liga- 
ment. 

In  ordinary  accidents,  the  internal  coagulum  contributes  to  the 
suppression  of  hemorrhage,  because  its  formation  is  uncertain,  and, 
when  formed,  it  rarely  fills  the  canal,  and  is  not  adherent  unless  the 
walls   have  been   lacerated   considerablv;  and  then  it  adheres  to  the 


12  The  Ligature  of  Arteries. 

lacerated  spots  first,  and  extends  a  long  distance  up  the  canal  of  the 
vessel. 

If  an  artery  has  been  partially  divided,  there  is  a  coagulum  be- 
tween the  vessel  and  its  sheath,  thickest  at  the  point  of  injury.  If 
the  vessel  is  small,  the  wound  is  closed  with  coagulated  lymph, 
which  surrounds  it  in  a  tumor-like  mass.  Wounds  less  than  one 
fourth  the  circumference  of  an  artery  in  extent  are  capable  of  heal- 
ing so  as  to  occasion  little  or  no  obstruction  in  the  canal.  The  fact 
is  noticed  by  Jones  and  other  observers,  that  it  is  extremely  diffi- 
cult to  produce  aneurism  in  dogs  and  horses  by  wounding  arteries. 

If  an  artery  is  surrounded  by  a  tight  ligature,  its  middle  and  in- 
ternal coats  will  be  as  completely  divided  as  by  a  knife;  the  exter- 
nal coat  remaining  entire.  The  strength  of  an  artery  depends 
chiefly  on  its  external  coat,  which  answers,  in  some  respects,  the  pur- 
pose of  a  strong  fascia.  If  no  branch  be  near,  a  coagulum  is  formed, 
which  is  of  little  consequence,  for  there  is  an  effusion  of  lymph  which 
unites  the  wounded  surface  and  forms  an  external  thickening,  which, 
involving  the  surrounding  parts,  covers  over  the  vessel  and  forms 
the  surface  of  the  wound.  The  ligature  ulcerates  through  the  ex- 
ternal coat,  and  the  vessel  is  obliterated  up  to  the  collateral  branches 
on  both  sides.  Jones  was  the  first  to  bring  to  prominence  the 
agency  of  the  walls  of  the  vessel  in  the  process  of  repair.  The 
organizable  lymph,  he  thought,  was  poured  out  from  the  vasa  vaso- 
rum,  repair  beginning  in  this  material,  and  not  in  the  coagulated 
lymph  of  the  clot  of  Hunter. 

The  researches  of  Hunter  and  Jones  gave  renewed  interest  to 
this  study,  and,  during  the  next  three  decades,  we  find  a  large  num- 
ber of  communications  upon  this  subject.  In  France,  Ribes,**  Bouil- 
laud,  Roche,  Sanson,  Blandin,^'  and  Gendrin''  pronounced  in  favor 
of  the  organizing  power  of  the  thrombus.  The  latter  writer  says:  "  If 
the  blood  is  enclosed  between  two  ligatures  in  an  artery  or  vein,  it 
coagulates  the  serum,  is  absorbed,  and  a  slight  inflammation  of  the 
walls  takes  place.  The  clot  decolorizes,  a  thin  layer  of  coagulable 
fluid  spreads  itself  over  the  inner  wall  of  the  vessel,  and  aids  in  the 
cohesion  of  the  thrombus,  which  finally  grows  to  the  wall  and  be- 
comes organized."  Henry  Lee,  repeating  Gendrin's  experiments, 
concluded  that  the  clot  acts  as  a  foreign  body,  setting  up  an  inflam- 
mation which  begins  in  the  outer  coat,  and  extends  to  the  inner  coat 
of  the  vessel;  a  natural  process  for  the  elimination  of  the  thrombus. 
He  concluded  also  that  an  effusion  of  lymph  from  the  living  mem- 
brane of  the  vessel  does  not  take  place.     Andral,^""  although  he  ac- 


History.  1 3 

cepted  the  popular  theory,   believed  also,  with  Cruveilhier,'"  in  an 
adhesive  inflammation  of  the  walls  of  the  vessel. 

Among  German  writers  may  be  mentioned  Meckel,  who  was 
among  the  first  to  call  attention  to  the  white  corpuscle,  though 
ascribing  to  it  no  special  role,  and  Phillip  v.  Walther,  who  accepted 
the  views  of  Hunter;  the  former,  however,  believing  that  the  vessel- 
walls  combined  with  the  clot  to  form  a  cicatricial  tissue.  On  the 
other  hand,  Ebel  denied  the  participation  of  the  internal  coagulum, 
as  did  also  Chelius,  and  Rust,  as  the  result  of  their  experience  in 
the  healing  of  wounds;  the  latter  maintaining  "  that  blood,  as  such, 
does  not  become  organized;  neither  vessel  nor  injection  mass  are 
found  to  penetrate  it  "  In  the  later  editions  of  their  works  they 
gave  their  adherence  to  the  views  of  Stilling,'^  whose  experimental 
researches,  the  most  extensive  since  Jones,  seem  to  have  definitely' 
settled  the  question  at  that  time  that  the  thrombus  did  become  organ- 
ized. The  results  of  Stilling' s  investigations  coincided  with  those 
of  Jones,  with  this  exception.  The  former  divided  the  process  of 
repair  of  the  thrombus  into  three  periods: — at  first  soft  and  succu- 
lent, the  clot  grows  denser,  at  the  same  time  diminishing  in  size:  it 
then  becomes  vascularized.  He  regards  the  vascular  spaces  as  si- 
nuses, and  compares  the  tissue  of  the  thrombus  to  that  of  the  pla- 
centa. The  third  period  includes  a  development  of  a  fine  connective- 
tissue,  which  becomes  completely  incorporated  with  the  vessel-wall, 
and  is  followed  by  a  retrograde  metamorphosis,  which  results  in  an 
absorption  of  the  vessel  and  thrombus  up  to  the  first  collateral  branch. 
The  tortuous  vessels  seen  subsequently  at  the  end  of  the  vessel- 
stump,  he  suggests,  are  those  developed  by  the  thrombus. 

In  Italy  we  find  Scarpa,  in  1817,  maintaining  the  adhesion  of  the 
walls  of  the  vessel  without  the  intervention  of  the  clot. 

Guthrie  ^°  called  attention  to  a  fact  not  to  be  forgotten  in  drawing 
conclusions  from  experiments  on  animals,  that  the  repair  of  their  ves- 
sels does  not  follow  the  same  course  as  in  the  case  of  man.  His 
account  of  the  process  is  exceedingly  accurate.  In  dogs,  if  an  artery 
be  wounded  through  more  than  three  quarters  of  its  circumference,  a 
coagulum  forms  and  extends  up  and  down  the  sheath,  the  cut  edges 
and  the  surrounding  parts  inflame,  and  throw  out  lymph, which  adheres 
to  and  surrounds  the  clot.  The  lymph  becomes  organized,  and 
unites  the  edges  so  as  to  leave  no  mark.  The  cicatrix  may,  how- 
ever, yield,  and,  as  in  man,  an  aneurism  will  be  formed.  In  man, 
a  longitudinal  slit  may  heal  without  obliteration  of  the  canal  in 
medium-sized  arteries,  as  the  temporal:  in  larger  vessels  the  canal 


14  TJic  Ligature  of  Arteries. 

becomes  obliterated.  If  completely  divided,  the  vessel  contracts  at 
its  end  at  first,  and  later,  at  about  an  inch  from  the  end,  this  sec- 
tion being  filled  with  a  coagulum.  Still  later  the  contraction  takes 
place  up  to  the  first  large  branch,  so  that,  out  of  four  or  five  inches, 
two  or  three  inches  will  be  impervious,  the  remaining  part  being 
very  much  narrowed.  Vessels  of  considerable  size  are  capable  of 
arresting  hemorrhage  without  aid,  the  power  and  influence  of  the  heart 
over  the  circulation  through  the  arteries  being  greatly  overrated. 

Amussat'°^  also  calls  attention  to  the  peculiarities  of  the  healing 
process  in  animals.  He  states  that  aneurism  can  never  be  produced 
in  dogs,  and  in  horses  only  the  arterio-venous  variety  is  observed. 
He  also  thinks  that  the  reparative  process  is  more  independent  of 
the  ligature  than  was  supposed  at  that  time.  Many  vessels  would 
cicatrize,  if  time  and  rest  were  given  them.  More  reliance  should 
be  placed  on  pressure.  Many  other  names  might  be  mentioned,  but 
the  authorities  quoted  serve  to  indicate  the  prevailing  opinion  of 
that  period. 

With  the  rise  and  progress  of  histological  research,  the  question 
of  the  organization  of  the  thrombus  was  subjected  to  new  tests. 
Schwann,  in  1838,  had  developed  his  "Cell  theory,"  according  to 
which  all  tissues  are  developed  from  primary  cells.  A  direct  change 
from  amorphous  blastema  could  therefore  no  longer  be  maintained, 
cells  forming  first  in  the  cytoblastema  or  fibrine,  from  which  the  new 
tissue  is  developed.  Henle^  however,  adhered  to  the  old  view  that 
the  coagulated  fibrine  was  immediately  changed  into  connective  tissue, 
and  it  was  under  his  direction,  that  Zwicky  "°  repeated  the  experi- 
ments of  Jones  and  Stilling,  adding  an  examination  of  the  thrombi 
under  high  powers  of  the  microscope.  This  was  the  first  elaborate 
microscopical  study  of  the  question.  The  special  point  to  be  deter- 
mined was  the  appearances  to  be  noted  in  the  development  of  fibrine 
mingled  with  blood  corpuscles;  the  "reorganization  of  the  blood 
in  substance"  was  not  doubted  by  Henle.  The  following  changes 
were  noted  in  the  thrombus.  At  about  the  fifth  day  certain  granular 
bodies  appear,  which,  it  is  assumed,  are  developed  directly  from  the 
fibrine;  these  do  not  appear  to  have  any  special  significance  for,  be- 
fore the  end  of  the  second  week,  they  have  broken  down.  By  the 
eleventh  day  the  fibrine  has  lost  its  fibrillated  appearance,  and  has 
become  a  homogeneous  structureless  cytoblastema.  At  the  beginning 
of  the  third  week  this  mass  begins  to  have  a  slightly  fibrillate  appear- 
ance longitudinally,  and,  at  the  sides,  band-like  fibres  are  noticed. 
Numerous  round  and  oval  granules  appear  on  the  addition  of  acetic 


History.  1 5 

acid,  and  near  them  are  red  granules,  the  remains  evidently,  of  broken 
down  blood  corpuscles.  The  broad  fibres  increase  in  number  until 
the  whole  mass  of  fibrine  has  been  thus  transformed.  They  appear, 
says  the  author,  uncommonly  like  muscular  fibres,  but  later  on, 
about  the  sixth  or  seventh  week,  these  fibres  become  still  further 
broken  up  into  wavy  fibrill^,  corresponding  to  those  seen  in  con- 
nective-tissue. The  red  blood  corpuscles  take  no  part  in  the  tissue- 
formation.  Zwicky,  like  Stilling,  observed  the  formation  of  vessels 
in  the  thrombus,  and  he  agreed  with  the  latter  that  it  became  organ- 
ized; but  he  did  not  find  the  subsequent  absorption  of  the  cicatrized 
thrombus  and  vessel  mentioned  by  that  investigator.  This  was  in 
direct  opposition  to  the  views  of  Rokitansky,'"^  whose  book  appeared 
the  previous  year,  in  giving  prominence  to  the  action  of  the  vessel- 
walls,  and  pointing  out  that  the  obliteration  of  the  portal  vessels  took 
place  without  the  intervention  of  a  thrombus.  Rokitansky  says: 
"■  We  believe  that  the  closure  of  a  ligatured  vessel  takes  place  with- 
out the  aid  of  the  thrombus,  the  inner  coagulum,  that  this  is  an  acci- 
dental formation,  and  by  no  means  a  condition  necessary  for  the 
obliterating  process.  We  are  of  the  opinion  that  the  closure  and 
obliteration  of  the  ligatured  vessel  is  essentially  the  same  process 
which  occurs  in  vessels  which  have 'been  excluded  from  the  active 
circulation,  and,  owing  to  the  change  in  the  blood  current,  have  be- 
come useless;  for  example,  the  umbilical  arteries  and  the  ductus 
Botalli.  The  end  of  the  ligatured  artery  having  become  closed  by 
a  fusion  of  the  inner  walls  thus  brought  into  contact,  the  further 
obliteration  takes  place  by  a  gradual  diversion  of  the  current  into 
collateral  channels,  and  a  corresponding  narrowing  of  the  cavity  of 
the  vessel  until  the  inner  wall  either  coalesces,  or  a  new  layer  de- 
posited upon  it  completely  closes  the  lumen.  The  so-called  vasculari- 
zation of  the  thrombus  we  have  never  observed,  and  believe  this 
condition  to  be  the  same  thing  as  that  remarkable  appearance  which 
we  have  recognized  as  canaliculization."  These  opinions,  it  should 
be  remembered,  were  expressed  at  a  time  when  the  views  of  Hunter, 
Schwann,  and  Henle  had  been  generally  adopted  by  the  scientific 
world. 

About  this  time,  the  work  of  Porta'"'  appeared,  a  contribution  to 
certain  branches  of  this  subject  too  elaborate  and  too  excellent  to 
be  passed  by  unnoticed.  He  made  a  special  study  of  the  collateral 
circulation,  and  of  the  kind  of  material  to  be  used  as  ligature. 

Virchow,  '°®  at  first,  was  more  or  less  influenced  by  Hunter's 
views  on  the  organizing  power  of  coagulated  fibrine;  when,  however, 


1 6  The  Ligature  of  Arteries. 

he  became  convinced  of  the  power  of  cell-action,  and  inaugurated 
the  modern  system  of  cellular  pathology  with  the  formula,  "  Omnis 
cellula  e  cellula,"  he  devoted  his  attention  to  the  action  of  the  white 
corpuscles,  found  in  the  thrombus,  particularly  in  his  studies  of 
thrombosis  and  embolism.  He  was  fully  convinced  of  the  organi- 
zation of  the  thrombus  ;  there  was  only  a  question  in  his  mind  as  to 
the  proper  interpretation  of  the  process.  He  says:  "There  is  cer- 
tainly no  doubt  that  organized  tissue  forms  in  those  places  where 
fibrine  or  blood  clot  previously  existed,  and  that  it  would  not  have 
been  developed,  had  not  the  clot  been  there."  Although  he  con- 
ceded that  the  vessels  of  the  thrombus  might  grow  from  the  vasa 
vasorum,  nevertheless,  he  did  not  think  that  the  presence  of  the  cel- 
lular element  of  the  new  tissue  could  be  explained  by  a  primary  growth 
inwards  of  the  cells  from  the  vessel-wall.  In  studying  the  contrac- 
tion of  the  thrombus,  in  1850,  he  noticed  that  the  white  corpuscles 
became  elongated,  egg-shaped,  and  spindle-shaped;  that  also,  when 
compressed  in  the  meshes  of  the  shrinking  clot,  the  cells  became 
extremely  elongated  or  stellate,  so  as  to  look  not  unlike  like  bone- 
tissue;  the  nuclei  also  became  elongated.  "  It  would  be  impossible 
to  believe,"  he  says,  "that  these  stellate  cells  are  originally  white 
corpuscles,  unless  one  had  seen,  as  here,  side  by  side,  all  stages  of 
development."  At  that  time  he  thought  the  cells  merel}'  passive  in 
their  changes.  In  a  second  series  of  experiments,  undertaken  the 
following  year,  Virchow  studied  the  earliest  changes,  as  seen  in  the 
membrane  formed  over  the  pyramidal  plugs  of  rubber  introduced 
into  the  pulmonary  arteries  of  dogs.  On  the  seventh  day,  the 
fibrine  was  homogeneous,  and  contained  stellate  cells,  partly  anasto- 
mosing with  one  another,  and  partly  isolated;  the  appearance  being, 
as  before,  not  unlike  ossifying  tissue.  As  early  as  the  second  day 
similar  changes  were  noticed,  and  he  was  forced  to  fall  back  upon 
the  white  corpuscle  seen  in  the  fibrine,  for  an  explanation  of  these 
phenomena;  and  he  says,  in  conclusion,  "  Must  we  not  concede  that 
white  corpuscles  may  be  the  originators  of  the  future  connective  tis- 
sue corpuscle  ?"  He  described  the  "  sinus-like  degeneration  "  as  the 
hollowing  out  of  channels  in  the  thrombus  by  the  blood-current, 
and  distinguished  it  carefully  from  the  vascularization  of  the 
thrombus. 

In  the  same  year  appeared  a  communication  from  Keinhardt"^ 
particularly  worthy  of  mention  for  the  correctness  of  certain  views 
which  hold  good  to-day.  He  disproves  the  direct  organization  of 
fibrinous  exudations,    deriving  young  tissue,    which    forms    on    its. 


History.  1 7 

site,  or  that  of  a  blood  clot,  from  the  surrounding  tissue;  the  forma- 
tive material  exuding  from  the  blood-vessel  being  transformed, 
according  to  the  Schwann  theory,  into  cells  capable  of  development. 
"As  the  new  tissue  grows  into  the  fibrine  the  latter  is  absorbed. 
There  is  no  trace  of  new  formation  of  nuclei  in  the  fibrine,  the  de- 
velopment of  the  young  tissue  takes  place  entirely  independently  of 
the  fibrine."  Concerning  the  organization  of  the  thrombus  he 
states:  "Around  the  ligature  the  tissue  becomes  inflamed,  and  in 
consequence  of  the  suppuration  which  takes  place,  granulations  form, 
which  mingle  with  the  cellular  tissue,  and  take  the  place  of  the  ne- 
crosed portion  of  the  vessel,  and  grow  into  the  thrombus  just  as 
new  tissue  grows  into  the  fibrine  in  the  healing  of  wounds."  He 
never  saw  any  such  changes  in  the  fibrine  as  were  observed  by  Zwicky, 
there  being  no  trace  of  organization  there:  it  was  amorphous  as  at 
first,  and  only  occasionally  were- granular  cells  to  be  seen  in  it,  these 
being  probably  pus  corpuscles.  Notta,"^  in  Paris,  maintained,  in 
a  thesis  published  in  the  same  year,  that  blood  clot  was  capable  only 
of  a  retrograde  change:  he,  like  Pouteau,  thought  that  cicatrization 
began  in  the  surrounding  cellular  tissue. 

Rokitansky,  in  1856,  yielded  so  much  to  the  prevailing  views  as 
to  allow,  in  certain  cases,  a  direct  organization  of  the  thrombus  into 
connective-tissue:  in  other  cases,  again,  it  was  reabsorbed,  and  in- 
dependent vascularization  did  not  take  place.  The  bulk  of  the 
growth,  he  still  maintained,  came  from  the  vessel-wall;  but  he  no 
longer  derived  it  from  the  plastic  exudation,  but  from  a  connective- 
tissue  growth  from  the  interior.  The  tide  had  now  fairly  turned, 
and,  under  the  stimulus  of  Virchow's  teaching  the  views  of  Schwann 
and  Henle  were  rapidly  disappearing,  but  his  opinion  on  the  organi- 
zation of  the  thrombus  restrained  for  some  time  a  farther  advance 
in  this  direction. 

The  work  of  C.  O.  Weber, '^5  confirming  Virchow's  views,  obtained 
general  acceptance  throughout  Germany,  and  is  even  to-day  an 
accepted  authority  in  many  text  books.  The  following  quotation 
expresses  his  views:  "Within  the  thrombus  the  organization  begins 
in  a  few  hours,  and  is  at  first  entirely  accomplished  by  the  so-called 
white  corpuscles.  The  red  blood-corpuscles  take  no  part  in  the 
process.  They  soon  yield  their  coloring  matter,  which  is  precipi- 
tated in  the  fibrine;  they  shrink,  and  break  down  more  or  less  rapidly. 
The  fibrine  of  the  blood  clot  cilso  breaks  down  into  a  fine  granular 
detritus.  The  striation  and  stratification  of  it  has  no  special  signifi- 
cance, for  the  fibrine  has  as  little  to  do  with  the  changes  as  the  red 
2 


1 8  TJie  Ligature  of  Arteries. 

corpuscles.  The  colorless  corpuscles  are  here,  as  elsewhere,  specially 
concerned  in  the  process  of  organization.  In  the  first  hours  after 
the  formation  of  the  clot,  these  bodies  are  seen  to  take  on  different 
forms;  occasionally  they  elongate  themselves  into  a  spindle-shape, 
the  mass  of  protoplasm  sending  out  on  both  sides  delicate  prolonga- 
tions which  unite  with  similar  ones  from  other  cells,  and,  by  dispos- 
ing themselves  side  by  side,  help  to  form  bundles  dotted  with  nuclear 
swellings;  or,  several  such  prolongations  will  be  thrown  out  in  dif- 
ferent directions,  producing  a  'Stellate  net-work,  with  nuclear  enlarge- 
ments, such  as  are  seen  in  young  connective  tissue,  which  grow  into 
and  occupy  all  parts  of  the  fibrinous  clot.  Finally,  an  enormous 
multiplication  of  these  bodies  takes  place;  they  undergo  segmen- 
tation, divide,  and  increase  rapidly:  and,  where  there  were  few  before 
we  now  find  large  masses  of  cells.  These  changes  transpire  during 
the  first  few  days  after  the  coagulation  of  the  thrombus.  At  the  end 
of  a  week,  canals  are  already  seen  running  in  various  directions 
through  the  thrombus  filled  with  rows  of  red  corpuscles."  That 
this  mesh-work  is  a  genuine  anastomosing  system  of  blood-vessels 
admits  of  no  doubt.  This  process  is  the  same  in  the  veins  as  in  the 
arteries,  and  the  smallest  branches  of  the  latter  give  the  same  ap- 
pearances as  those  seen  in  the  large  trunks.  In  thrombi  adhering  to 
one  side  of  the  vessel-wall,  particularly  those  formed  in  the  pockets 
of  the  valves  of  veins,  the  same  changes  may  be  observed.  In  this 
way  the  "  vascularization  "  is  effected  by  the  white  corpuscles,  which 
are  the  sole  organizing  elements  in  the  thrombus,  through  the  canali- 
culization  of  the  thrombus  which  precedes;  and  it  is  finall)^  completed 
when  the  young  vessels  become  united  with  those  of  the  vessel-wall. 
The  "  canaliculization  "  of  the  thrombus  is  the  name  given  to  the 
formation  of  the  canal,  and  it  precedes  the  "  vascularization  "  or  the 
union  of  the  canals  with  the  vasa  vasorum.  These  blood -canals 
appear  to  form  by  the  longitudinal  grouping  of  spindle-cells,  or  by 
the  dilatation  of  the  anastomosing  processes  of  young  connective  tis- 
sue cells  into  a  tubular  system,  and  are  found,  first  in  the  periphery, 
and  later,  in  the  centre  of  the  clot.  They  join  those  of  the  vessel- 
wall  in  the  third  or  fourth  week.  These  vessels  pass  into  the  throm- 
bus at  the  point  of  ligature,  but  sometimes  higher  up.  Bj'  the  sixtieth 
day  the  thrombus  is  full  of  vessels,  and  there  is  usually  a  large  one 
in  the  centre.  1-ater,  the  thrombus  shrinks  to  a  small  connective- 
tissue  plug. 

According    to    Rindfleisch  '•"   also,    the    first    changes  occur  in 
the  white  corpuscles;  a  delicate  protoplasma  net-work  being  formed, 


History^  19 

with  nuclei  at  the  point  of  union  of  the  meshes.  He  likens  the  clot 
to  a  connective  substance  in  which  the  white  corpuscles  represent  the 
cells,  and  the  red  corpuscles  and  the  fibrine  the  matrix.  The  later 
changes  of  the  organized  thrombus  he  describes  as  the  cavernous 
metamorphosis. 

In  spite  of  the  weight  of  such  authorities,  there  were  still  those 
who  did  not  accept  the  theory  of  the  organization  of  the  thrombus, 
and,  with  the  investigations  on  the  action  of  the  endothelium,  the 
study  of  this  question  entered  upon  a  new  phase. 

Cohn,'=®in  i860,  was  the  first  to  suggest  these  cells  as  organizing 
elements,  and  Lanceraux,  speaking  of  the  fate  of  the  embolus,  states 
that  it  disappeared  as  pseudo-membranous  formations  grew  into  it 
from  the  vessel-wall.  Foerster,  also,  could  not  convince  himself  of 
such  an  organization  of  the  thrombus,  and  so  states  in  his  text  book 
published  at  that  time.  He  doubts  also  whether  the  white  corpuscles 
undergo  any  such  changes  as  were  described  by  Virchow.  About 
this  time  came  also  an  important  communication  from  that  eminent 
histologist  His,'«  which  did  away  with  one  of  the  strongest  objec- 
tions to  the  theory  of  the  activity  of  the  lining  membrane  of  the  ves- 
sel in  adhesive  inflammation.  His  showed  that  the  cells  of  this 
structure  were  of  an  essentially  different  origin  from  the  epithelium 
of  the  skin  and  mucous  membrane,  that  they  arose  from  the  middle 
germinal  membrane,  belonged  to  the  group  of  connective  substances, 
lined  the  inner  wall  of  the  blood  and  lymphatic  vessels,  the  serous 
membranes  and  the  surfaces  of  joints,  and  gave  them  the  present 
name  "  endothelium."  Waldeyer,'5+  consequently,  recognizing  that 
the  endothelium  was  capable  of  producing  connective  tissue,  and 
that,  by  its  growth,  genuine  granulations  could  be  produced,  con- 
vinced himself  that  this  tunic  took  an  active  part  by  producing  a 
young  vascular  connective  tissue  within  the  vessel.  He  says:  "  The 
so-called  organization  of  the  thrombus  and  of  extravasation  of  blood 
occurs  from  the  vessel-wall  or  from  the  neighborhood  of  the  extrava- 
sations; and,  in  the  case  of  the  vessels,  the  epithelium  plays  the 
most  important  role  by  growing  into  the  thrombus.  The  intima 
becomes  vascularized  through  the  media,  capillary  loops  shoot  into 
the  thrombus,  accompanied  by  delicate  bands  of  spindle-cells  which 
form  the  basis  of  the  future  connective  tissue.  The  extravasated 
blood  never  organizes,  but  is  invariably  absorbed,  leaving  behind 
more  or  less  coloring  matter." 

The  investigations  of  Recklinghausen,''"  which  led  to  the  discov- 
ery of  the  wandering  cells,   and  the   re-discovery  by  Conheim   of 


20  TJic  Ligature  of  Arteries. 

Waller's  observations  of  the  passage  of  the  white  corpuscles  through 
the  walls  of  blood-vessels  gave  a  new  turn  to  the  discussion.  Here, 
then,  was  a  fertile  source,  whence  a  supply  of  cells  could  be  ob- 
tained, wherewith  to  people  the  thrombus,  the  study  of  which,  like 
any  other  departments  of  pathology,  was  strongly  influenced  by  these 
important  contributions  to  medical  science.  A  pupil  of  Reckling- 
hausen, Bubnoff,'-"  undertook  to  demonstrate  the  passage  of  such 
cells  through  the  walls  of  veins  which  had  been  tied.  After  the  liga- 
ture had  been  applied,  granules  of  vermilion  were  rubbed  over  the 
vessel  externally,  and  were  found  to  be  taken  up  by  the  wandering 
cells,  and  to  be  carried  into  the  thrombus  through  the  vessel-wall. 
Bubnoff  concludes,  "  that  the  white  corpuscles  of  the  thrombus  lose 
their  power  of  wandering,  and  take  no  part  in  the  cell-formation  of 
the  organizing  tissue.  Cells  take  part  in  the  organization  of  the 
thrombus,  which  creep  in  large  numbers  into  the  vein.  The  mass 
of  the  cells  are  probably  derived  from  the  layers  of  the  vessel-walls, 
and  from  the  surrounding  tissues."  Billroth  '3?  adopted  these  views, 
but  still  maintained  that  proliferation  took  place  in  the  white  corpus- 
cles of  the  thrombus.  While  the  view  of  Conheim  '"^  as  to  the  ori- 
gin of  cells  in  inflamed  tissues,  was  adopted  by  a  large  number  of 
pathologists,  there  were  those  who  still  believed  that  the  pre-existing 
cells  of  the  part  were  capable  of  proliferation.  The  most  prominent 
exponent  of  this  school  is  Strieker,  who  goes  so  far  as  to  believe  in 
a  subdivision  of  even  the  intercellular  substance,  and  its  conversion 
into  amoeboid  material.  The  artery,  with  its  delicate  lining  of  cells, 
easily  isolated  from  surrounding  tissue,  seemed  particularly  adapted 
to  test  the  disputed  points,  and  many  of  the  papers  subsequently 
produced  were  written  by  adherents  of  Conheim  or  of  Strieker. 
Argument  and  investigation  were  now  employed  chiefly  to  determine 
the  relative  merits  of  the  emigration  and  proliferation  theories,  both 
parties  conceding  that  the  thrombus  in  the  old  sense  could  not  be- 
come organized. 

Thiersch  '5°  arrayed  himself  with  those  who  saw  in  the  new  cells 
a  "  proliferating  vessel-epithelium,"  and  believed  that  the  vasculari- 
zation of  the  thrombus  was  effected  partially,  if  not  entirely,  by 
these  cells.  In  sections  through  the  epithelial  covering  of  the  folli- 
cle, and  through  a  part  of  the  coagulum  of  a  corpus  luteum  of  the 
sow,  he  observed  newly  formed  large  cell-masses,  interspersed  with 
vessels  which  projected  in  a  series  of  loops  into  the  clot,  in  the  white 
corpuscles  of  which  no  change  could  be  observed.  This  explained 
Bubnoff's    results  with  vermilion    granules    by   assuming   that    the 


History.  2 1 

granules  were  not  carried  by  cells,  but  floated  in  the  plasmatic  cur- 
rent,which  flowed  through  the  intercellular  spaces  of  a  network  which 
forms  around  wounded  vessels,  and  were  thus  carried  into  the  in- 
terior of  the  vessel.  Bubnoff  repeated  the  experiments  the  follow- 
ing year  with  reference  to  the  objections  raised  by  Thiersch,  but 
still  held  fast  to  the  view  that  the  wandering  cells  were  the  sole 
transports  of  the  pigment-granules. 

Kocher  "^  and  Szuman  endeavored  to  restore  the  Weber  theory 
of  the  organization  of  the  thrombus,  and  they  appear  to  have 
been  the  last  to  uphold  it.  The  work  of  both  writers  was  largely 
devoted  to  the  changes  found  in  acupressure.  Kocher  gave  special 
attention  to  the  action  of  the  endothelium,  and  convinced  himself 
that  it  not  only  took  no  part  in  the  process,  but  even  hindered  it. 
The  vascularization  could  not,  therefore,  take  place  through  these 
cells;  and,  in  further  support  of  this  view,  he  showed  that  the  larger 
vessels  are  always  in  communication  with  the  lumen  of  the  vessel, 
and  are  never  found  to  make  their  way  through  the  uninjured  wall. 
After  the  double  ligature  of  a  vessel,  the  blood  having  first  been  ex- 
cluded, no  union  of  the  walls  of  the  isolated  portion  takes  place. 
The  theory  of  Deschamp  and  Lawson  Tait,'"*'  of  union  by  first  in- 
tention, he  does  not  think  tenable.  The  comparison  of  the  intima 
with  the  peritoneum  is  not  justifiable:  it  would  be  more  correct  to 
liken  the  adventitia  to  the  peritoneum  and  its  action  in  suture  of 
the  intestine.  Moreover,  in  some  cases  the  intima  and  media  are 
separated  from  their  corresponding  layers,  and  therefore  it  is  im- 
possible for  them  to  unite  by  first  intention.  The  union  of  the 
adventitia  is  doubtful,  for  it  is  not  probable  that  it  would  be  able  to 
resist  the  blood  pressure.  The  thrombus  is  therefore,  in  Kocher's 
opinion,  the  most  important  factor  in  the  temporary  and  final  sup- 
pression of  hemorrhage.  Even  in  cases  where  the  thrombus  is 
exceedingly  small,  owing  to  the  presence  of  a  branch,  we  find  it 
driven  in  between  the  clefts  in  the  vessel-walls;  thus  affording  its 
protecting  influence.  The  clefts  in  the  walls  are  not,  of  themselves, 
sufficient  to  check  the  blood-current;  for,  if  the  ligature  be  imme- 
diately removed,  the  circulation  is  restored.  On  the  other  hand,  if 
these  ruptures  are  not  made  by  the  ligature,  the  blood  will  remain 
fluid,  and,  when  released,  will  mingle  again  with  the  current.  We 
must  have,  therefore,  not  only  obstruction  to  the  circulation,  but 
simultaneous  bruising  of  the  vessel-wall,  to  produce  conditions 
favorable  to  permanent  closure.  The  old  view  of  Petit,  on  the  effi- 
ciency of  the  inner  coagulum,  he  thinks  still  holds  good.     In  small 


22  TJie  Ligature  of  Arteries. 

vessels  temporary  pressure  may  sufifice,  owing  to  the  rapid  re-estab- 
lishment of  the  collateral  circulation.  The  pressure  exerted  by  the 
coagulum  of  extravasated  blood  acts  in  this  way.  As  to  the  canali- 
zation of  the  thrombus,  it  is  thus  explained.  According  to  the 
manner  in  which  the  fibrine  is  deposited  the  blood  will  take  certain 
directions  in  filtering  through  the  clot,  as  changes  are  going  on  in 
it,  and,  on  the  borders  of  the  canals  thus  formed,  a  growth  of  con- 
nective tissue  takes  place  by  the  development  of  the  white  corpuscles 
into  spindle-shaped  cells. 

Szuman  '*»  agreed  essentially  with  Weber,  but  did  not  accept  the 
latter's  theory  of  the  formation  of  vessels  by  the  tubular  metamor- 
phosis of  the  prolongations  of  cells.  In  the  same  number  of  the 
journal,  in  which  Kocher's  article  appeared,  there  was  one  also  by 
Tschausoff,'*s  which  takes  directly  opposing  ground.  This  investi- 
gation included,  in  addition  to  those  on  animals,  several  on  the 
human  subject,  among  which  appears  a  specimen  taken  from  the 
brachial  artery  of  a  stump  twelve  years  after  amputation.  Tschausoff 
concluded  that  the  thrombus  takes  no  part  in  the  organization,  but 
breaks  down  in  all  its  elements,  as  the  growth  forms  from  the  vessel- 
walls;  the  function  of  the  thrombus  being  merely  to  offer  a  tem- 
porary protection  against  hemorrhage.  The  cicatrization  is  accom- 
plished by  the  connective-tissue  elements  of  the  vessel-walls.  The 
thrombus  and  ligatures  are  the  source  of  irritation  which  produces 
this  growth.  Neither  muscular  fibres,  nor  endothelium,  take  any 
part  in  the  process:  the  new  vessels  form  entirely  from  the  vessel- 
walls.  The  work  of  this  observer,  being  a  graduation  thesis,  and 
but  very  crudely  illustrated,  was  hardly  equal  to  sustaining  so  inde- 
pendent a  position. 

Cornil  and  Ranvier'^-"  conclude  from  their  studies  that  the  ob- 
literation of  the  artery,  after  ligature,  is  affected  by  a  new  formation, 
produced  by  an  arteritis,  the  result  of  the  traumatic  lesion  springing 
from  the  intima.  The  early  changes  noted  in  this  coat  are  swelling 
of  the  cells,  and  multiplication  of  the  nuclei,  and  a  few  days  later, 
a  thickening  of  the  intima  by  cells  which  appear  fusiform,  but  are 
really  flattened.  These  resemble  endothelial  cells  or  connective 
tissue  cells  swollen  by  inflammation.  They  differ  in  no  way  from 
those  seen  in  acute  endarteritis.  By  the  eighth  day  granulations 
are  formed:  by  the  fourteenth,  these  contain  capillaries.  Gradually 
the  outline  of  the  coat  is  lost,  and  the  capillaries  appear  to  come 
from  the  vasa  vasorum.  As  the  granulations  fuse  together,  the  clot 
disappears:    it  does  not  become  organized.     The  wandering  of  cells 


History.  23 

through  the  walls  of  vessels  after  single  ligature  does  not  take  place. 
Bubnoff's  experiments  still  remained  the  subject  of  much  controversy. 
It  was  conceded  by  Mayer'"  that  the  cells  found  in  the  early  periods 
in  the  thrombus  were  the  product  of  the  white  corpuscles,  and  the 
wandering  cells;  but  he  also  maintained  the  growth  from  the  vessel- 
wall.  Durante  '^°  made  the  vermilion  experiment  and  the  double 
ligature  the  objects  of  a  special  study.  He  found  that  the  walls  of 
the  vessel  between  the  two  ligatures  undergo  a  necrosis,  and  that 
the  white  corpuscles  penetrate  them,  as  they  would  an  inert  body. 
In  single  ligature  he  could  not  find  cells  containing  granules  either 
in  the  clot  or  the  walls  of  the  vessel.  If  the  pigment  be  rubbed  in 
hard,  he  has  occasionally  found  it  inside  the  veins  in  a  free  state. 
He  therefore  concludes  that  the  wandering  cells  have  nothing  to  do 
with  the  process,  and  attributes  the  work  to  the  endothelium,  or  the 
layer  of  ramified  cells  found  beneath  the  endothelium  in  the  intima. 

Maunder, '95  in  a  series  of  lectures,  gives  some  valuable  hints  as 
to  the  formation  of  the  blood  clot.  A  ligature,  he  says,  to  be  suc- 
cessful, must  give  rise  to  an  inflammatory  process  in  the  shape  of 
adhesion  of  the  cut  surfaces  and  of  the  divided  coats,  and  a  destruc- 
tive process  in  the  shape  of  ulceration,  by  which  the  ligature  is  to  be 
cut  loose.  According  to  Lister  and  Callender  the  greater  turmoil 
in  which  the  blood  is  thrown  on  the  cardiac  side,  by  impinging  against 
the  obstruction,  accounts  for  the  more  rapid  coagulation  on  that 
side  of  the  ligature.  This  churning  process  leads  to  the  deposit  of 
fibrine  more  or  less  pure;  the  deposit  of  blood  clot,  on  the  other 
hand,  is  formed  by  slowness  of  movement,  as  on  the  distal  side  in 
the  lower  extremity  when  the  anastomosis  is  not  free.  In  a  case  of 
secondary  hemorrhage,  after  an  antiseptic  catgut  ligature,  it  is  in- 
teresting to  note  that,  subsequently  it  was  found  that  the  inner 
coats  of  the  vessel  had  not  been  divided,  and  that  there  was  little 
clot  on  either  side. 

A  decided  advance  in  our  knowledge  of  this  process  was  made 
by  Baumgarten.  -°°  As  the  title  of  the  article  indicates,  the 
author  still  felt  the  necessity  of  combating  the  old  theory,  and 
he  maintains  that  in  all  his  experiments,  which  were  conducted 
antiseptically,  no  clot  was  formed.  But  it  was  chiefly  from 
his  observations  on  the  growth  of  granulations  from  the  sur- 
rounding external  tissues  into  the  interior  of  the  vessel,  that  his 
monograph  acquires  especial  interest.  The  pressure  of  the  liga- 
ture, he  says,  absorbs  the  bridge  of  adventitial  tissue,  and  the  sur- 
rounding granulation  tissue  grows  in  between  the  ends  of  the  media. 


24  The  Ligatiu'c  of  Arteries. 

or  through  other  ruptures  in  the  sides  of  the  wall.  This  tissue  is 
the  source  of  the  vascularization  of  the  thrombus,  for  the  pure  en- 
dothelial growth  which  also  occurs  is  without  vessels.  This  shows 
that,  in  the  developed  organism,  a  new  formation  of  blood-vessels 
occurs  only  in  conjunction  with  pre-existing  blood  tubes.  Baum- 
garten's  work  included,  also,  a  very  careful  study  of  the  behavior  of 
the  endothelial  cells.  An  irritation  being  produced  upon  the  adven- 
titial and  the  peri-adventitial  tissue,  by  the  ligature,  the  nutrition  of 
the  endothelium,  which  is  dependent  upon  the  vasa  vasorum,  must 
be  affected;  and  we  find  a  cloudy  swelling  of  its  cells  and  prolifera- 
tion. These  change  also  into  a  cube-shaped  endothelium.  There 
soon  appears  to  be  a  new  layer  of  tissue  between  the  original  en- 
dothelium and  the  lamina.  It  is  interesting  to  note  that  he  mentions, 
in  the  outer  layer  of  this  new  cell-structure,  some  cells  like  those 
described  by  Heubner  in  syphilitic  arteries  as  resembling  muscular 
cells,  but  all  this  new  tissue  develops  into  a  connective  tissue  finally. 
He  thus  recognizes,  in  the  new  tissue,  a  central  portion  composed  of 
granulation  tissue  containing  vessels,  and  a  peripheral  non-vascular 
tissue  composed  of  endothelial  cells.  He  does  not  believe  that  the 
white  corpuscles  of  the  thrombus  take  any  part  in  the  new  forma- 
tion.    He  considers  the  endothelium  the  most  important  factor. 

It  appears  that  the  cumulative  evidence  produced  at  this  period 
was  not  without  its  influence  upon  the  standard  authorities;  for 
Billroth,  who,  in  accepting  the  views  of  Conheim  and  Recklinghausen 
on  the  action  of  the  wandering  cell,  had  said,  "  After  having  aban- 
doned the  idea  of  proliferation  of  stable  tissue  cells  in  inflammation, 
we  can  no  longer  talk  of  the  proliferation  of  intima  in  the  old  sense," 
now  suggested  to  two  of  his  pupils  the  advisability  of  going  over  the 
ground  again;  and,  as  a  result,  there  appeared  articles  by  Raab  on 
the  cicatrix  following  ligature,  and  by  Winiwarter  on  endarteritis; 
both  of  whom  endorsed  strongly  the  theory  of  an  active  endothelium 
growth.  Raab  ^**  placed  double  ligatures  on  the  walls  of  veins  and 
arteries  in  such  a  way  as  to  exclude  the  blood  clot,  and  to  avoid 
injury,  as  much  as  possible,  to  the  vasa  vasorum  by  stripping  up  the 
sheath.  Cross  sections  of  arteries  prepared  in  this  way  on  the 
twelfth  day  show  a  marked  change  in  the  endothelium,  oblong  or 
spindle-shaped  cells  filling  out  the  folds  in  the  lamina  with  an  abun- 
dant intercellular  substance,  and,  on  the  surface,  presenting  a  normal 
endothelial  covering.  This  tissue  becomes  fibrous  later,  but  never 
vascular  except  near  the  ligatures.  In  veins,  at  the  same  period,  we 
find  a  proliferation  in  the  outer  coats,  and,  as  there  is  no  lamina  to 


History.  25 

oppose  a  barrier  to  these  cells,  they  become  mingled  with  the  grow- 
ing endothelium.  The  new  tissue  in  this  case  is,  therefore,  more 
like  granulation-tissue.  The  earliest  changes  seen  in  endothelial 
cells  is  best  observed  in  cross  sections  of  small  vessels.  An  en- 
largement of  the  nuclei  occurs,  which  pushes  out  the  cells  more 
prominently  into  the  lumen.  Th«  old  nucleus  disappears  finally, 
several  new  ones  take  its  place,  and  an  active  proliferation  becomes 
apparent.  In  veins,  the  round  cells  prevail  as  a  type;  in  the  arteries, 
flat  and  spindle-shaped  cells  prevail.  These  cells  get  their  nutri- 
ment from  the  vasa  vasorum,  and,  if  we  wish  to  study  the  changes 
in  them,  the  vasa  vasorum  must  not  be  destroyed.  Raab  calls  par- 
ticular attention  to  the  ramification  of  spindle-cells  from  the  intima 
into  the  clot,  seen  well  at  the  fourth  day.  Some  of  these  anastomo- 
sing structures  are  described  as  protoplasmic  masses,  in  which,  later, 
nuclei  are  developed,  eithef  by  a  differentiation  of  the  material,  or 
by  their  being  carried  to  a  certain  point  by  a  fluid  stream  in  the  mass. 
Later,  these  cells  collect  into  bundles  covered  with  endothelial  cells, 
and,  anastomosing  with  one  another,  leave  spaces  like  those  de- 
scribed by  Weber,  and  incorrectly  supposed  to  be  newly  formed  ves- 
sels. Still  later,  they  assume  the  appearance  of  granulations.  Vessels 
come  from  the  walls,  finally,  through  the  injured  spots  near  the  liga- 
ture. There  is,  also,  at  those  points,  some  growth  of  connective- 
tissue  into  the  vessel.  Dudukaloff  ascribes  the  chief  work  to  this 
granulation  tissue;  according  to  Raab,  it  is  sometimes  the  endothe- 
lial and  sometimes  the  granulation-cells  which  predominate,  probably 
according  to  the  injury  done  by  the  ligature.  In  the  most  favorable 
cases  we  may  have  union  by  first  intention  through  a  growth  of  the 
endothelium  solely.  The  organized  tissue  consists  first  of  cells; 
later,  of  cells,  fibres,  and  vessels.  Gradually,  with  increasing  age, 
the  cells  disappear,  as  do  also  the  vessels,  and  a  fibrous  band  re- 
mains as  the  permanent  cicatrix. 

The  old  view  that  a  thrombus  must  reach  as  far  as  the  first  col- 
lateral branch,  is  exploded,  both  through  experiments  on  animals 
and  through  observation  on  man.  There  is  no  way  of  controlling 
its  growth.  As  to  the  question  of  the  organization  of  the  thrombus, 
Raab  denies  participation  of  the  included  white  corpuscles;  as  white 
corpuscles  may  be  produced  from  endothelium,  it  is  not  necessary 
to  account  for  their  increased  numbers  by  supposing  an  immigration 
of  wandering  cells.  He  could  not  reproduce  Bubnoff's  experiments. 
As  other  cells  may  take  up  pigment  granules,  their  presence  in  the 
new  tissue  does  not  afford  evidence  of  a  participation  of  the  white 


26  '  The  Ligature  of  Arteries. 

corpuscles.  Wandering  cells  may  be  found  in  the  thrombi  of  veins, 
but  their  action  there  is  doubtful.  The  growth  of  endothelium  and 
of  granulations  is  as  easily  demonstrated  as  any  fact  in  pathological 
histology,  but  the  question  of  the  action  of  white  corpuscles  and 
wandering  cells  is  founded  on  the  doubtful  basis  of  hypothesis.  A 
portion  of  the  clot  is  taken  up  by  the  current  and  carried  into  the 
circulation,  another  portion  is  consumed  and  assimilated  by  the 
young  tissue,  till  finally  only  a  few  hematoidin  crystals  or  amorphous 
pigment  granules  bear  witness  to  the  presence  of  blood. 

The  study  of  idiopathic  endarteritis  has  contributed  much  to  the 
belief  that  the  endothelium  plays  an  important  role  in  the  pathologi- 
cal changes  in  disease  of  arteries.  According  to  Cornil  and  Ranvier, 
in  chronic  endarteritis  in  vessels  of  small  calibre,  such  as  are  seen 
at  the  base  of  the  brain,  the  internal  tunic  has  vegetated  in  such  a 
way  as  to  obliterate  completely  the  vessel;  and  in  the  tissue  thus 
formed,  we  may  have  a  new  formation  of  blood-vessels.  In  the  en- 
darteritis, which  precedes  aneurism,  a  similar  growth  is  noticed, 
which  may  either  narrow  the  vessel  or  project  into  its  lumen  in 
granulation-like  masses.  It  is  worthy  of  notice  that,  in  the  dilata- 
tion of  aneurism,  as  described  by  these  authors,  rupture  of  the  media 
takes  place,  and  the  adventitia  and  the  intima  become  united,  vessels 
growing  into  the  latter  from  the  former;  conditions  closely  resem- 
bling those  produced  by  the  ligature.  Heubner,  in  studying  the 
changes  in  the  cerebral  artery  in  syphilis,  observed  a  growth  in  the 
deep  layer  of  the  intima.-  In  the  space  between  the  endothelium  and 
the  lamina  there  is  a  single  layer  of  nuclei,  imbedded  in  a  granular 
cloudy  substance.  Protoplasm  formed  about  these  cells,  and  new 
cells  were  also  produced  by  a  proliferation  of  the  endothelial  cells, 
which  onl)'  grew  outward  into  this  layer,  and  not  into  the  lumen. 
They  eventually  formed  a  new  lamina;  in  fact,  a  new  membrane, 
similar  to  the  normal  membrane,  was  produced.  Friedlander,  in 
describing  such  a  growth  between  the  lamina  and  the  endothelial 
layer,  in  obliterating  arteritis,  suggests  that  the  new  cell-growth  may 
come  from  cells  which  emigrated  from  the  vasa  vasorum,  and  that 
the  endothelium,  and  also  the  white  corpuscles  of  the  blood,  may 
participate.  Winiwarter's  =°7  observations  were  made  on  a  single  case, 
but  they  are  given  as  an  example  of  the  minute  changes  observed  in 
this  disease.  In  the  small  arteries,  the  lumen  was  nearly  filled  with 
a  new  cell-growth;  in  the  centre  was  an  irregularly  shaped  lumen 
surrounded  by  endothelial-like  cells,  outside  of  which  were  circularly 
arranged  spindle-shaped  cells,  and  fibrous  tissue  giving  the  impres- 


History.  27 

sion  of  a  newly  formed  vessel.  Sometimes  two  such  vessels  were 
seen.  The  muscular  walls  were  thickened  by  an  increase  partly  of 
the  muscular  cells,  and  partly  by  cell-infiltration  occurring  seconda- 
rily, by  an  invasion  from  the  intima;  or  we  may  have  the  lumen 
completely  filled  with  a  concentrically  arranged  connective-tissue, 
the  lamina  disappearing  entirely.  In  the  tibial  artery  the  intima 
was  greatly  thickened,  and  Winiwarter  found  in  the  new  growth 
several  white  concentric  circular  bands  which  he  calls  newly  formed 
elastic  laminae,  between  which  spindle  and  irregular  shaped  cells  were 
found;  further  in  was  a  myxomatous  tissue,  and  if  the  blood  clot 
was  adherent,  these  cells  grew  into  it,  or  a  new  endothelial  mem- 
brane was  formed  by  short  spindle-cells  closely  packed  together.  A 
number  of  arterioles  were  seen  giving  the  tissue  a  cavernous  appear- 
ance. In  some  places  the  lamina  was  found  to  become  granular, 
then  fibrillated,  and  then  to  break  up  and  be  reflected  backwards, 
permitting  a  growth  of  the  cells  into  the  media.  In  some  cases  a 
new  lamina  is  found  just  beneath  the  endothelium,  outside  of  this 
being  a  concentric  layer  of  fibres,  giving  the  appearance  of  a  new 
vessel-wall  formed  inside  the  old  one. 

In  the  veins  there  is  a  considerable  thickening  of  the  intima,  gen- 
erally on  one  side,  complete  obliteration  only  taking  place  by  the 
formation  of  a  thrombus.  The  inner  layer  of  this  growth  is  com- 
posed of  a  more  abundant  mucous  tissue  than  in  the  arteries,  and  is 
covered  by  a  growth  of  round  cells,  and  not  covered,  as  in  the 
arteries,  by  an  endothelium;  consequently,  coagulation  easily  takes 
place.  Outside  of  this  layer,  and  close  to  the  lamina,  is  a  layer  of 
spindle-cells  closely  resembling  circular  muscular  fibres.  The 
growth  described  in  these  vessels  arises,  according  to  the  author, 
from  the  intima,  and  chiefly  from  the  endothelium,  the  media  and 
adventitia  playing  a  subordinate  role.  The  finally  obliterating  tissue 
is  a  fibrous  tissue  rich  in  cells,  and  the  subsequent  formation  of 
blood-spaces  is  purely  mechanical,  being  caused  by  the  blood-current 
forcing  its  way  through  the  tender  tissue.  They  may,  in  their  turn, 
be  obliterated  by  a  further  growth,  there  being  a  constant  struggle, 
as  it  were,  between  the  blood  current  on  one  side,  and  the  new 
growth  on  the  other.  The  new  laminae  are  probably  formed  from 
endothelial  cells,  which  are  closely  pressed  together,  become  flat  and 
stationary,  and  lose  their  nuclei.  The  muscular  cells  are  found  only 
in  the  veins,  which  have,  in  the  lower  extremity,  such  cells  normally 
in  the  intima. 

The  smaller  vessels  become  more  quickly  obliterated  than  the 


28  TJie  Ligature  of  Arteries. 

larger,  being  converted  into  a  fibrous  cord.  Tiie  new  vessels  form 
a  sort  of  collateral  circulation. 

Wyeth^^o  finds,  in  traumatic  arteritis  from  external  injury,  a 
hyperemia  with  cell-emigration  and  proliferation  in  the  arterial  coat, 
the  connective  tissue  cells  of  the  adventitia,  the  white  corpuscles, 
and  the  endothelium  all  taking  part.  The  vessel  is  narrowed  by  a 
growth  from  the  intima,  and  capillaries  finally  find  their  way  into 
this  new  tissue.  In  idiopathic  endarteritis  the  growth  occurs  primarily 
in  the  intima,  the  outer  coat  being  affected  secondarily.  In  syphili- 
tic arteritis  Wyeth  observed  an  irregular  thickening  of  the  external 
coat,  but  he  found  the  chief  change  in  the  intima;  although,  in  two 
cases  observed  by  Greenfield,  all  coats  suffered  some  change.  In 
his  illustrations  some  spindle-shaped  cells  are  seen,  and  also,  in  one 
case,  a  newly  formed  elastic  lamina. 

It  will  be  seen  that  the  weight  of  evidence  appears  to  be  strongly 
in  favor  of  a  growth  of  the  cells  of  the  intima,  and,  at  the  present 
day,  this  seems  to  be  the  generally  accepted  view;  although  a  few 
still  hold  to  a  participation  of  the  white  corpuscles  to  a  certain  de- 
gree. For  instance,  Lee  and  Beale  '^^  made  investigations  on  the 
arteries  of  horses  and  of  a  donkey,  to  show  that  repair  did  not  take 
place  by  means  of  adhesive  inflammation  of  the  internal  wall  of  the 
vessel.  After  describing  the  external  clot  they  state,  "  The  opening 
in  the  elastic  coat  of  the  vessel  is  not,  however,  immediately  occupied 
by  blood,  but,  as  has  been  shown,  is  gradually  filled  up  with  a  per- 
fectly colorless  substance.  This  material,  which  resembles  the  fibrine 
found  in  some  aneurismal  sacs,  is  like  that  substance,  deposited  from 
the  blood,  layer  after  layer,  until  the  space  is  filled  up.  Sometimes 
the  process  continues  until  an  actual  elevation,  projecting  above  the 
level  of  the  inner  surface  of  the  artery,  is  formed."  Of  the  laminae 
of  transparent  fibrine  they  say,  "  It  is  evident  they  have  been  formed 
from  the  blood  which  flowed  along  the  vessel,  and  not  from  any 
material  poured  out  from  beneath  by  the  vasa  vasorum  or  from 
arterial  tissues.  We  do  not,  however,  regard  the  material  as  a  new 
deposit  of  fibrine  from  the  blood,  but  are  disposed  to  think  that  it  is 
formed  by  the  agency  of  the  white  blood  corpuscles  which  we  know 
would  adhere  to  the  surface  of  the  blood-clot  which  occupies  the 
lower  part  of  the  wound.  It  seems  probable  that  these  masses  of 
germinal  matter,  as  they  slpwly  move  over  the  surface,  form  the 
material  allied  to  fibrine  figured  in  the  drawings."  Later  changes 
than  those  seen  at  three  days  were  not  studied,  but  the  authors  leave 
it  to  be  inferred  that,  in  their  opinion,  it  is  probable  that  a  connec- 


History.  29 

tive  tissue  cicatrix  may  be  formed  from  tlie  material  described, 
although  they  do  not  deny  that  it  may  be  derived  from  the  cells  of 
the  arterial  wall,  "which  may  gradually  increase  in  number  near  the 
cut  surface  of  the  vessel,  and  thus  extend  from  this  point  into  the 
temporary  texture  occupying  the  wound." 

This  line  of  investigation  was  continued  by  Schultz,^'"^  who  main- 
tains that  the  process  of  repair  is  completed  exclusively  by  the  white 
corpuscles  in  the  vessel.  The  gaping  wound,  made  by  a  longitudi- 
nal incision,  is  filled  by  a  clump  of  white  corpuscles,  which  become 
fused  together  (white  thrombi)  into  a  homogeneous  fibrinous  mass, 
the  corpuscles  ceasing  to  perform  any  further  act  as  soon  as  they  are 
caught  in  the  clot.  Subsequently,  this  mass  is  seamed  with  a  series 
of  canal-like  spaces  ("  canalized  fibrine  ").  This  fibrine  forms  a  sort 
of  sac  at  the  mouth  of  the  vvound.  The  canals  are  filled  subse- 
quently with  more  white  corpuscles,  which  multiply  rapidly  until  the 
fibrine  disappears,  and  granulations  are  found  in  its  place,  between 
which,  as  the  wound  is  filled,  spaces  are  left  which  gradually  are 
formed  into  small  vessels.  The  cells  on  the  outside  of  the  vessel, 
being  shut  out  by  the  fibrine  layer,  have  nothing  to  do  with  the 
process.  The  sac  in  aneurism  is  formed  from  such  a  layer  of  fibrine. 
Experimenting  with  the  double  ligature,  Schultz  found  no  sign  of 
action  in  the  endothelium.  An  important  and  original  observation 
is  made  in  this  paper  upon  the  eventual  shape  of  the  cicatrix.  If 
there  be  no  branch  near,  the  cicatricial  tissue  will  be  symmetrically 
developed  in  a  crescent  shape;  but  should  such  a  branch  exist,  the 
new  tissue  will  be  built  up  on  the  opposite  side.  If  several  branches 
are  given  off,  one  beyond  the  other,  there  will  be  a  thickening  of 
the  new  tissue  opposite  each,  and  the  cicatrix  may  be  continued  in 
this  shape  some  distance  up  the  side  of  the  vessel  (see  Thoma.). 

Schultz's  paper  brought  out  a  reply  from  Pfitzer,^"  according  to 
whom  such  wounds  are  filled  with  the  white  thrombus,  inside  of 
which  a  growth  of  endothelium  takes  place  over  the  wound,  and  a 
granulation  tissue  is  formed  at  the  same  time  outside  of  the  vessel 
at  the  same  point;  these  two  growths  finally  displacing  the  clot  be- 
tween them.  The  walls  of  the  vessel  remain  gaping  as  on  the  first 
day,  and  are  held  by  the  connective  tissue  cicatrix.  These  are 
practically  the  views  of  Baumgarten,  to  whom  Senftleben  ="=  replied 
in  the  same  number  of  the  Archives.  A  curious  and  interesting 
series  of  experiments  was  made  with  the  double  ligature  to  prove 
the  inactivity  of  the  endothelium  and  the  part  played  by  the  wan- 
dering cells.     In  the   usual  experiment  with  the  double  ligature  he 


30  The  Ligature  of  Arteries. 

found  no  change  in  the  walls  of  the  vessel,  except  close  to  the  thread, 
where  there  was  a  slight  spindle-cell  growth  closing  the  vessel  inside, 
and  also  a  slight  infiltration  of  the  media  and  of  the  adventitia.  In 
case  of  suppuration  some  pus-cells  were  also  found  inside;  if  no 
suppuration  occurred,  only  a  few  epithelioid  (granulation)  cells  and 
giant-cells  were  found  in  the  blood  which  flowed  out  on  opening  the 
vessel.  When  a  saline  solution,  with  vermilion  in  suspension,  was 
introduced  into  the  circulation,  pigment  particles  were  afterwards 
found  in  the  cells  inside  the  segment,  showing  that  they  were  cells 
wandering  from  the  small  vessels  into  this  space.  This  segment 
was  eventually  converted  into  a  solid  cord  by  a  growth  penetrating 
at  the  ligatured  point.  In  one  case  a  double-ligatured  segment  was 
filled  with  alcohol  so  as  to  destroy  the  lining  endothelium,  and  yet 
the  process  was  in  no  way  changed.  In  another  series  of  experi- 
ments the  double-ligatured  portion  was  immediately  removed,  and, 
having  been  soaked  for  two  days  in  alcohol,  was  placed  in  the  peri- 
toneal cavity  of  rabbits.  The  same  form  of  spindle-cell  growth  was 
found  inside  these  spaces  as  that  described  by  Raab  as  coming  from 
the  endothelium,  although  here  those  cells  were  manifestly  destroyed. 
Wandering  cells  were  also  found  in  the  walls.  The  swollen  en- 
dothelium described  by  Raab,  he  thinks,  was  probably  attached 
white  corpuscles.  If  such  views  were  correct,  then  we  should  have 
all  small  vessels,  in  an  inflamed  part,  obliterated.  The  endothelium 
may  be  stimulated  into  reproduction  by  inflammation,  but  this  limits 
itself  to  a  regenerative  process.  The  new  endothelium  is,  however, 
formed  from  the  vessels  in  the  neighborhood,  the  ligatured  vessel 
being  converted  into  a  cord.  The  arteritis  produced  by  the  ligature 
differs  in  no  way  from  other  forms  of  obliterating  arteritis.  Even  in 
the  syphilitic  form,  the  walls  are  mfiltrated  with  wandering  cells. 
Baumgarten,  in  answer,  says  that  there  may  be  white  corpuscles  in 
the  new  tissue,  but  that  they  have  nothing  to  do  with  the  healing 
process.  The  genuine  formative  cells  are  the  so-called  epithelioid 
cells  (large  cells  with  one  or  more  nuclei),  and  these,  he  claims,  are 
absolutely  identical  in  form  with  the  first  descendants  of  the  grow 
ing  vessel-endothelium.  In  repeating  Senftleben's  experiments,  he 
found  no  wandering  through  the  walls  of  pieces  of  vessel  placed  in 
the  abdominal  cavity,  but  if  left  there  long  enough,  the  ends  might 
be  absorbed,  and  granulation  tissue  could  then  grow  in.  Senftleben 
used  also  pieces  of  lung,  and  saw  the  immigration  of  wandering 
cells,  and  their  change  to  spindle-cells:  in  the  centre  were  broken 
down  white  corpuscles.     Baumgarten  saw  in  this  fatty  degeneration 


History.  3 1 

an  evidence  that  the  white  corpuscles  are  of  no  importance.  The 
spindle-cells  found  there  are  the  result  of  an  ingrowth  of  granula- 
tion tissue. 

Shakespeare-'^  derives  the  new  formation  from  the  endothelium 
and  the  subjacent  cellular  elements  of  the  intima.  Already  at  the 
end  of  twenty-four  hours  a  collection  of  these  cells  is  seen,  at  the 
point  of  ligature,  forming  a  cushion  on  which  the  clot  is  seen  resting. 
The  latter  this  observer  styles  the  fibrinous  clot,  and  the  former  the 
plastic  clot.  The  plastic  clot  is  composed  of  cells  of  a  great  variety 
of  shapes,  and  it  continues  to  grow,  pushing  up  the  fibrinous  clot. 
On  the  sides,  the  growth  of  the  cellular  covering  of  the  intima  some- 
times extends  as  far  as  the  first  collateral  branch.  It  begins  to  show 
signs  of  vascularization  as  early  as  the  sixth  day;  later  a  rich  capil- 
lary net-work  is  seen  in  communication  with  the  open  lumen.  A 
communication  is  effected  with  the  vessels  of  the  walls  of  the  artery 
between  the  fifteenth  and  thirtieth  day,  at  the  bottom  of  the  arterial 
stump,  where  the  intima  and  media  have  been  cut  through  by  the 
ligature.  The  plastic  clot  cicatrizes,  undergoes  cavernous  trans- 
formation, and  finally  disappears,  the  only  remains  of  the  vessel  and 
the  clot  being  a  tough  fibrous  cord.  If  pressure  be  exerted  upon  the 
wall  of  the  vessel  just  above  the  point  of  ligature,  sufficient  to  bruise 
the  inner  wall,  there  is  an  accumulation  of  cells  in  the  intima  and 
inner  layers  of  the  media,  the  plastic  clot  forming  mainly  at  that 
point  instead  of  at  the  level  of  the  ligature.  By  compressing  an 
artery  for  a  few  hours  with  a  pair  of  forceps  or  a  serre-fine,  an  in- 
flammation may  be  excited  by  which  the  lumen  may  become  oblit- 
erated. This  method  is  suggested  in  cases  of  atheroma  or  aneurism. 
The  author  has  actually  observed  the  separation  of  an  endothelial 
cell  from  the  wall  of  a  capillary  in  the  frog's  mesentery,  during  in- 
flammation. He  concludes  that  the  endothelium  may  be  the  origin 
of  some  of  the  white  blood  corpuscles  and  of  the  unusual  number 
seen  in  inflammatory  processes.  He  has  carefully  studied  the 
formation  of  the  blood  clot,  which  he  finds  forms  gradually,  and 
presents  a  stratified  aspect,  having  the  appearance  of  a  column  of 
red  blood  surrounded  by  fibrine  and  white  corpuscles  coiled  up  in 
the  vessel.  The  tendency  of  a  slowly  moving  blood  column,  to 
retain  a  shape  impressed  upon  it,  can  be  demonstrated  under  the 
microscope  in  the  tongue  of  the  frog.  The  apex  is  composed  of  a 
homogeneous  clot  containing  some  large  ovoid  cells.  The  blood 
clot  acts  merely  as  a  foreign  body,  producing  a  certain  amount  of 
circulation,  and  finally  disintegrates  slowly.     The  white  corpuscles 


32  The  Ligature  of  Arteries. 

and  the  wandering  cells  take  no  part  in  the  organizing  process. 
Zahn  '9-*  has  recently  performed  a  series  of  experiments  somewhat 
similar  to  that  of  Shakespeare's  fifth  series.  A  strong  silk  ligature 
was  applied  to  the  carotid  or  femoral  of  a  rabbit,  and,  a  minute 
later,  removed.  Vermilion  granules  were  occasionally  applied  out- 
side the  vessel.  The  intima  and  three  quarters  of  the  media  were 
found  cut  through.  Endothelium  began  in  a  day  or  two  to  form  at 
the  edges  of  the  rent,  and  later  grew  into  it,  and  finally  filled  it  up. 
There  was  no  cell  proliferation  in  the  media,  and  the  muscular  fibres 
remained  unchanged.  The  adventitia  was  at  first  hyperemic,  and  a 
cell-proliferation  took  place  later.  The  vermilion  granules  were 
found,  either  outside  or  inside  of  cells,  and  extended  as  far  as  the 
media,  but  never  into  the  cicatricial  tissue.  As  no  aneurismal  dila- 
tation occurred,  he  infers  that  the  remaining  media  and  adventitia 
were  sufficient  to  prevent  that  occurrence.  G.  Simon  has  called 
attention  to  ruptures,  like  those  in  the  arteries  of  persons  who  have 
been  hanged,  and  he  infers  that,  if  such  individuals  were  restored  to 
life,  they  would  ev^entually  die  of  aneurismal  dilatation,  or  thrombo- 
sis of  the  vessel.  This  author's  experiments  on  animals  show  this 
view  to  be  groundless.  His  former  opinion  as  to  the  participation 
of  the  connective  tissue  of  the  media  was  not  borne  out,  nor  does 
the  adventitia  take  any  part  in  the  repair.  He  is  sceptical  as  to 
whether  a  white  corpuscle  can  form  genuine  connective  tissues. 

A  very  interesting  series  of  observations  have  been  made  by 
Thoma--*  on  a  formation  of  connective  tissues  in  the  deeper  layers 
of  the  intima  of  arteries,  under  certain  conditions,  or  what  may  be 
called  a  compensatory  endarteritis,  such  as  is  seen  in  the  kidneys  in 
chronic  nephritis.  At  birth  the  change  takes  place  in  the  Ductus 
Botalli  and  in  the  umbilical  arteries,  producing  an  almost  complete 
closure  of  those  vessels,  and  spreads  out  over  nearly  the  whole  tract 
concerned  during  foetal  life  in  the  umbilical  circulation.  (Nabel- 
blutbahn).  It  is  particularly  marked  in  the  descending  aorta.  It 
consists  of  a  hyaline  connective-tissue  at  some  points,  containing 
large  spindle-shaped  cells  and  branching  cells  anastomosing  with 
one  another.  This  is  a  physiological  example  of  what  occurs  in 
nephritis,  the  capillary  circulation  in  the  kidney  being  to  a  great 
extent  destroyed;  the  arteries  are  too  large  for  their  purpose,  and 
are  thus  correspondingly  diminished  in  calibre.  In  amputation 
stumps  he  finds  the  vessels  narrowing  from  their  point  of  origin, 
finally  becoming  continuous  with  a  more  or  less  solid  cord,  which 
reaches  to  the  cicatrix;    much  less  frequently  the  cord  is  patent  in 


History.  33 

its  entire  extent.  It  may  or  may  not  be  narrower  than  the  vessel  of 
the  opposite  limb;  in  this  latter  case  it  ends  as  a  blind  cul-de-sac 
from  which  a  bunch  of  small  arterial  twigs  spread  out  in  the  cica- 
tricial tissue. 

Verneuil's  measurements  showed  that  the  vessels  regularly  nar- 
rowed up  to  their  origin  from  the  aorta  and  vena  cava.  The  three 
important  changes  which  occur  in  these  vessels  are:  ist,  a  contraction 
of  the  media;  2d,  compensatory  endarteritis;  3d,  atrophy  of  the 
muscular  coat.  The  same  changes  occur  after  ligature  in  the  con- 
tinuity, but  to  a  less  degree,  owing  to  the  collateral  circulation. 
His  observations  confirm  those  of  Schultz  on  the  ultimate  shape  and 
size  of  the  cicatrix.  The  contraction  of  the  vessel  is  effected,  ac- 
cording to  Thoma,  through  the  Pacinian  bodies  which  are  found  in 
all  parts  of  the  arterial  system,  and  lie  in  the  outermost  zone  of  the 
adventitia;  they  are  able,  therefore,  to  perceive  the  slightest  vibra- 
tion in  the  arterial  walls  and  transmit  a  stimulus  to  the  nerves  of  the 
muscle  of  the  vessel.  The  closure  of  an  artery,  whether  physiologi- 
cally or  as  the  result  of  an  operation,  depends  upon  the  slowing  of 
the  current,  but  not  upon  the  lateral  pressure  of  the  blood.  It 
begins  with  a  contraction  of  the  media.  If  this  be  sufficient  to 
restore  the  normal  rapidity  of  the  circulation,  further  changes  are 
confined  to  an  atrophy  of  the  muscular  walls  sufficient  to  correspond 
with  the  diminished  calibre  and  diminished  tension.  If  this  should 
not  suffice,  it  Is  supplemented  by  a  compensatory  thickening  of  the 
intima. 

According  to  Senn,=3=  whose  experiments  were  made  upon  sheep, 
the  thrombus  is  accidental,  never  undergoes  organization,  and 
takes  no  part  in  the  obliteration  of  the  vessel.  The  final  cica- 
trix is  the  exclusive  product  of  connective  tissue  and  endothelial 
proliferation.  Permanent  obliteration  takes  place  in  arteries  in  from 
four  to  seven  days.  He  strongly  favors  the  catgut  ligature,  which, 
applied  according  to  his  method,  does  not  destroy  the  continuity  of 
the  vessel,  and  even  adds  to  the  strength  of  the  extra  vascular  cica- 
trix. In  many  of  his  cases  the  internal  tunics  were  intact.  Adopt- 
ing this  precaution,  and  applying  two  ligatures,  the  inner  surface 
can  be  brought  into  contact  over  a  larger  area  and  a  more  extensive 
surface  for  cicatrization  can  thus  be  utilized.  This  he  regards  as 
a  special  advantage  where  the  vessel  must  be  tied  near  a  collateral 
branch. 

Wyeth=3o  also  thinks  that  division  of  the  inner  and  middle  coats 
is  unnecessary.      He  has  specimens  from  animals  and   man  showing 
3 


34  Tlic  Ligature  of  Arteries. 

successful  occlusion  of  the  vessel  without  division  of  either  of  the 
tunics.  It  is,  he  considers,  a  safer  method.  The  thrombus  disai> 
pears  by  fatty  degeneration,  and  permanent  closure  is  effected  by 
cells  of  the  intima. 

The  question  of  placing  a  double  ligature  upon  the  vessel  and 
dividing  the  artery  between  them  has  recently  been  revived,  and  is 
of  interest  from  its  bearing  upon  the  process  of  repair.  Walsham 
adopted  this  method,  employing  as  ligature  carbolized  nerve.  He 
considers  the  amount  of  separation  of  the  artery  from  its  sheath  a 
factor  as  important  in  influencing  the  result  as  tightness  of  the  liga- 
ture or  division  of  the  coats,  since  the  vitality  of  the  artery  depends, 
in  a  great  measure,  upon  the  blood-supply  received  from  the  sheath. 
For  this  reason.  Savory  advocates  opening  the  sheath  with  the  knife 
instead  of  the  director.  The  blood  supply  of  the  distal  side  will  be 
more  affected  than  that  of  the  proximal  side,  since  the  vessels  run 
in  that  direction.  He  cites  a  case  where  a  fragment  of  the  vessel 
came  away  with  the  catgut  ligature,  in  illustration  of  this  point. 

In  reply.  Holmes  finds  an  objection  to  this  procedure  in  the  free 
dissection  and  exposure  of  the  vessels  necessary.  The  interference 
of  the  blood-supply  from  the  vasa  vasorum  is  very  transitory.  "  If 
an  artery  be  securely  tied  with  a  material  which  will  keep  its  hold 
on  the  vessel  until  the  seat  of  the  ligature  is  buried  in  a  mass  of 
new  fibroid  material,  secondary  hemorrhage,  if  not  impossible,  is, 
at  least,  very  improbable."  The  method,  he  says,  passed  out 
of  use  when  secondary  hemorrhage  was  common,  to  be  brought 
back,  when  it  is  rare.  Of  interest  in  this  connection  is  a  quotation 
from  Schultz,  who  says  that,  if  the  internal  coats  are  cut,  the  ad- 
ventitia  has  to  support  the  blood  column,  and  is  put  on  the  stretch 
by  the  retracting  vessels.  If  these  are  softened  by  inflammation 
there  may  be  perforation.  Suture  of  the  sheath  of  the  vessel  may 
give  an  extra  support,  or  the  application  of  two  ligatures  and  division 
of  the  artery  may  allow  it  to  retract.  Walsham  also  points  out  that 
if  the  ligature  should  cut  in  this  way,  the  transverse  incision  assumes 
a  diamond  shape,  and,  if  the  connection  of  the  internal  thrombus 
with  the  vessel-wall  were  slight,  it  would  be  disturbed.  The  method 
is  an  old  one,  and  was  looked  upon  with  favor  by  Jones  who  says, 
that,  "in  the  single  ligature,  although  the  knot  is  soon  covered  up 
and  protected  by  an  effusion  of  lymph,  it  is  placed  in  the  centre  of 
a  portion  detached  from  the  surrounding  cellular  membrane,  and 
the  process  of  repair  cannot  go  on  so  well,  since  the  nutritive  vessels 
are  cut  off.     In  the  double  ligature  the  knots  are  placed  where  the 


History.  35 

connection  of  the  vessel  with  the  surrounding  tissues  is  complete." 
It  had  also  the  sanction  of  Abernethy,  and  still  has  that  of  Maunder. 

Torsion,  as  has  already  been  shown,  was  known  to  the  ancients, 
and  was  employed  by  certain  surgeons  during  the  Middle  Ages, 
but  in  more  modern  times,  it  was  not  recognized  apparently  by 
the  surgical  world  until  brought  to  the  notice  of  the  leading  French 
surgeons  of  the  early  part  of  the  present  century. 

Velpeau^5  relates  that  Professor  Grossi  of  Munich,  being  at  Paris 
in  1826,  mentioned  the  fact  that  his  colleague  Dr.  Koch  had  not 
used  ligatures  in  amputations  for  twenty  years;  precisely  what  the 
method  employed  by  him  was,  is  not  stated.  This  conversation  led 
to  experiments  upon  animals  in  which  Velpeau  found  that  simple 
pressure  with  the  tip  of  the  finger  at  the  ends  of  vessels  was  sufficient 
to  prevent  further  bleeding.  He  also  found  abundant  confirmation 
in  literature  of  the  fact  that  the  circulation  was  not  entirely  under  con- 
trol of  the  heart,  and  that  local  conditions  often  sufficed  to  enable  even 
large  vessels  to  be  injured  without  bleeding.  Experiments  were  also 
made  in  "  froissement,"  "fermeture,"  "  renversement,"  and  "tor- 
sion." He  tried  the  latter  method  in  consequence  of  his  experience, 
when  a  student  with  a  veterinary  surgeon,  in  spaying  cows,  the 
pedicle  being  twisted  after  the  ovary  had  been  removed.  He  also 
tried  it  in  castration.  The  method  employed  by  Velpeau  is  thus  de- 
scribed: "After  having  seized  the  vessel  by  its  extremity,  I  separate 
it  from  the  surrounding  tissues,  and  grasp  it  at  its  deepest  point  in 
the  wound  with  another  forceps  to  hold  it  firmly  while  it  is  turned 
on  its  axis  three  to  eight  times  by  the  first  pair  of  forceps."  Vel- 
peau appears  to  have  employed  the  method  in  several  amputations. 
"  It  is  not  to  be  denied,"  he  says,  "  that  the  ligature  will  be  as  easy 
to  use  as  torsion,  and  perhaps  it  will  be  more  serviceable  in  the 
hands  of  the  majority  of  practitioners."  He  adds  "  that  it  may  be 
preferred  in  those  cases  where  it  is  desirable  not  to  leave  a  foreign 
body  in  the  wound;  animal  ligatures  would  not  be  less  valuable  for 
this  purpose,  if  we  would  undertake  to  try  them,  than  torsion."  He 
recognizes  the  disadvantages  of  torsion  in  diseased  vessels,  and  also 
that  small  vessels  are  not  easily  isolated.  According  to  Bryant, '5? 
Amussat"'^  was  the  first  to  communicate  a  paper  on  this  subject  to 
the  Academy  in  1829.  He  was  led  to  employ  it  from  his  experience 
with  torn  vessels.  Certain  it  is  that  the  method  was  taken  up  by 
some  of  the  best  surgeons  of  France  and  Germany,  but  later  fell 
into  disuse.  In  England,  little  notice  was  taken  of  it  in  spite  of 
a  paper  by  Costello  in  1834.     The  effect  of  torsion,  Bryant  states, 


36  T]ic  Ligature  of  Aj't cries. 

is  a  twisting  of  the  elastic  fibres  of  the  adventitia  about  the  end  of 
the  vessel,  and  a  retraction  and  incurvation  of  the  middle  and  inner 
coats.  The  twist  in  the  outer  coat  is  permanent,  and  cannot  be  un- 
folded by  any  legitimate  force.  The  middle,  and  the  inner  coats, 
are  retracted  in  the  direction  opposed  to  the  blood-stream,  approxi- 
mated, and  overlapped.  They  sometimes  assume  a  nipple-shaped 
projection;  at  others,  a  valvular  form,  not  unlike  the  semi-lunar 
valves  of  the  heart  and  closing  as  perfectly.  In  some  cases, 
again,  they  appear  to  split;  in  all,  the  coagulation  of  the  blood  is 
favored.  The  ampulla-like  dilatation  of  the  vessel  seen  at  the  proxi- 
mal side  is  attributed  to  the  fact  that  the  coagulation  forms  here 
first,  and  prevents  that  close  contraction  of  the  parietes  which 
goes  on  in  other  parts,  and  thus  an  apparent  dilatation  is  formed. 
The  safety  from  hemorrhage  in  torsion  rests  upon  the  twist  of  the 
external,  the  retraction  of  the  internal  coats,  and  the  coagulation 
down  to  the  first  branch,  in  acupressure,  the  permanent  safety  de- 
pending upon  the  last  alone,  temporary  protection  being  afforded  by 
the  needle. 

Kocher's  experiments  demonstrate  numerous  and  irregular 
lacerations  of  the  inner  coats,  over  a  considerable  distance  of  the  wall, 
and  independent  of  one  another;  in  ligature  the  rupture  being  cir- 
cular and  very  close  to  the  ligature.  There  is  also  the  narrowing  of 
the  lumen.  Owing  to  these  peculiarities,  torsion  enjoys,  with  acu- 
torsion  and  acupressure,  the  great  advantage  of  favoring  a  rapid 
coagulation,  and  also  has  its  own  special  advantage  of  producing  a 
much  more  intimate  union  between  the  thrombus  and  the  vessel- 
walls.  The  thrombus  plays  here,  also,  the  most  important  part  in 
hemostasis.  These  advantages  are  specially  true  of  illimited  torsion; 
when  properly  done,  it  is  the  ideal  for  small  arteries.  Torsion  is  not 
probably  available  for  larger  vessels,  on  account  of  the  force  of  the 
current,  which  would  untwist  the  vessel;  but  this  objection  does  not 
hold  good  in  acupressure  which,  in  Kocher's  opinion,  is  likely  to 
supersede  the  ligature. 

Shakespeare -'3  confirms,  in  the  main,  Brj'ant's  description  of  the 
mechanical  effect  upon  the  vessel,  but  adds  that,  by  pressure  of  the 
lirniting  forceps,  the  internal  tunic  of  the  artery  is  rubbed  together 
a  little  distance  above  the  end  of  the  arterial  stump,  producing  a 
result  similar  to  that  already  described  in  what  he  calls  the  "  modi- 
fied ligature."  "This  is  the  point  where  the  healing  process  is 
again  most  active,  where  the  granulations  spring  from  the  proliferat- 
ing intima,  and  where,  by  the  union  of  the  latter,  and  the  subsequent 


History.  37 

changes  which  have  already  been  mentioned,  the  kimen  of  the  ves- 
sel is  first  permanently  closed." 

Ogston"^  found  that  the  calibre  of  the  vessel  was  closed  by  the 
intermingled  ends  of  the  fibres  of  the  external  coat,  forming  a 
thimble-shaped  termination  enclosing  the  ragged  ends  of  the  middle 
and  internal  coats,  which  were  irregularly  folded  back  for  the  space 
of  a  quarter  of  an  inch  or  so  into  the  bore  of  the  artery. 

Sir  James  Simpson, '='  contrasting  the  healing  of  stumps  with  the 
rapid  union  following  operations  for  the  relief  of  vesico-vaginal 
fistula,  in  spite  of  the  contact  with  urine  and  leucorrhoeal  discharges, 
saw,  in  the  ligature,  one  of  the  chief  obstacles  to  healing  by  first 
intention.  It  not  only  acts,  he  thinks,  as  a  foreign  body,  but  cuts 
through  two  of  the  coats  at  the  time  of  its  application,  and  eats 
through  the  outer  coat  by  the  process  of  ulceration,  mortification, 
and  suppuration.  In  earlier  times,  attempts  were  made  to  overcome 
this  difficulty,  by  including  portions  of  the  surrounding  tissues  in  the 
ligature,  but  this  was  found  unnecessarily  severe;  hence  the  rule  of 
including  nothing  but  the  vessel.  Later,  large  and  flattish  ligatures 
were  employed.  These  ulcerated  slowly,  and  were  afterwards  re- 
placed by  those  as  slender  and  small  as  was  compatible  with  due 
strength.  Afterwards  endeavors  were  made  to  reduce  the  bulk  of 
the  foreign  body  by  cutting  off  the  end  of  the  knot.  To  cut  both 
ends  was  also  proposed,  but  the  procedure  was  not  successful. 
Animal  ligatures  were  tried,  and  metallic  ligatures  also,  but  Simp- 
son found  that  they  usually  excited  too  high  a  degree  of  inflamma- 
tion. It  was  for  these  reasons  that  he  proposed  the  substitution  of 
acupressure  for  the  old  method,  basing  the  use  of  the  needle  on 
what  he  calls  the  "  great  pathological  law  of  the  tolerance  of  living 
tissue  for  the  contact  of  metallic  bodies  imbedded  in  their  sub- 
stance." Simpson  thought  that  the  inner  coats  were  not  divided  as 
in  the  ligature.  Bryant  denies  that  the  ligatured  portion  sloughs, 
and  is  discharged;  on  the  contrary  it  becomes  adherent  and  vascu- 
larized, as  surgeons  who  have  been  obliged  to  open  an  amputated 
stump  must  have  noticed. 

Hewson  '=8  reports  a  study  of  several  specimens  of  human  arteries 
upon  which  acupressure  had  been  performed.  The  opposite  sur- 
faces of  the  internal  coat  were  glued  together  by  lymph,  the  exuda- 
tion both  inside  and  outside  of  the  vessel  being  very  extensive. 
There  was  no  clot  beyond  the  point  of  pressure,  and  no  laceration 
of  the  internal  coat. 

According  to  Kocher,'**  the  first  effect  of  the  needle  is  to  produce 


38  TJic  Ligature  of  Arteries. 

longitudinal  slits  in  the  intima,  but  not  to  the  same  extent  as  in  tor- 
sion. Both  in  acupressure  and  acutorsion  the  walls  of  the  vessels 
are  thrown  into  folds  and  pressed  together,  and  the  subsequent  in- 
flammation thickens  them  and  glues  them  together,  so  that,  when 
the  needle  is  removed,  they  still  preserve  the  shape  given  to  them, 
and  offer  a  sufficient  obstacle  to  the  flow  of  blood.  At  first  there  is 
no  thrombus,  and  a  fine  probe  can  be  passed  in  through  the  end  of 
the  vessel,  but,  as  the  blood  forces  its  way  between  the  folds,  the 
rents  favor  coagulation,  and  a  clot  forms  at  this  point,  resembling  a 
cork,  which  does  not  project  beyond  the  neck  of  the  bottle;  toward 
the  lumen  it  is  concave,  and  on  the  other  side  convex.  This  proba- 
bly occurs  earlier  than  in  ligature,  which,  according  to  Cooper,  takes 
sometimes,  forty-eight  hours.  In  acutorsion  the  vessel  is  narrowed 
for  some  distance  from  its  end,  and  coagulation  is  still  further 
favored  by  this  circumstance.  Gradually  the  walls  yield,  and  as 
they  separate,  the  thrombus  becomes  wider  and  larger,  but  retains 
a  firm  hold,  owing  to  the  slits,  through  which,  eventually,  vessels 
find  their  way  from  the  thrombus,  which  now  has  become  organized. 
The  ligature  could  not  be  removed  as  early  as  the  needle,  as  the 
action  is  more  local;  it  cuts  through  both  intima  and  media,  and  the 
adventitia  is  so  constricted  that  inflammatory  swelling  cannot  take 
place,  and  sloughing  is  the  result.  In  acupressure  in  the  continuity, 
the  proximal  and  the  peripheral  ends  of  the  thrombus  are  continu- 
ous, as  are  also  the  walls  of  the  vessel,  which  are  thickened  by  a 
connective-tissue  growth,  a  vascularized  tissue  extending  from  the 
thrombus  into  the  walls. 

Shakespeare  experimented  with  the  third  and  fourth  methods  of 
acupressure,  and  found  that  the  process  of  healing  was  very  similar 
to  that  which  secures  obliteration  of  the  artery  after  ligature.  In 
the  fourth  method,  or  acutorsion,  the  process  was  more  active. 
The  needles  were  allowed  to  remain  in  until  the  specimen  was 
placed  in  alcohol,  and,  in  the  drawing  given  (of  a  specimen  thirty-six 
hours  old),  there  is  no  such  patency  of  the  end  of  the  vessel  as  is 
described  by  Kocher,  nor  is  there  any  such  thickening  of  the  wall 
at  the  point  of  pressure  as  he  represents.  Moreover,  the  throm- 
bus, instead  of  being  concave  toward  the  lumen,  as  Kocher  says,  has 
its  usual  ovoid  shape. 

Ogston  has  tested,  mechanically,  the  comparative  strength  of 
arteries  secured  by  the  methods  of  ligature,  acupressure,  and  tor- 
sion. By  experiment,  he  estimated  the  internal  blood-pressure  in 
the  human  subject  at  from  two  to  eight  pounds  to  the  square  inch. 


History.  39- 

Arteries  were  now  taken  from  a  fresh  cadaver  and  subjected  to  liga- 
ture, torsion,  and  acupressure,  and  then  attached  by  the  cardiac  end 
to  a  cokimn  of  mercury.  It  was  found  that  a  column  one  hundred 
and  fourteen  inches  in  height  was  insufificient  to  rupture  the  liga- 
tured artery.  In  twisted  vessels  the  artery  unfolded  at  an  average 
height  of  thirteen  inches  (or  6.5  pounds  to  the  square  inch  pressure), 
i.e.,  not  up  to  the  requisite  resistance.  He  concludes  that  it  would 
appear  likely  that  vessels  secured  by  torsion  are  very  liable  to 
secondary  hemorrhage,  especially  when  the  heart,  recovering  from 
the  immediate  shock  of  an  operation,  begins  to  beat  more  firmly. 
The  acupressure,  the  fourth  method  of  Pirrie,  (which  he  consider*- 
the  strongest),  was  tried.  The  column  of  mercury  showed  an  aver- 
age of  twenty-three  and  a  half  inches.  It  would,  therefore,  seem  a 
more  trustworthy  method  than  torsion,  and  less  than  ligature.  Tor- 
sion may,  however,  be  used  in  small  vessels  when  the  thickness  and 
contractile  power  of  the  muscular  coat,  as  well  as  the  comparative 
amount  of  tissue  included  in  the  forceps,  favor  its  employment. 
Acupressure  and  torsion  are  also  considered  by  Shakespeare  as  in- 
ferior to  ligature,  owing  to  the  greater  slowness  of  the  healing  pro- 
cess. Kocher  suggests  that  acutorsion  and  acupressure  would  be 
well  adapted  to  diseased  arteries. 

LIGATURES. 

It  is  due  chiefly  to  Jones's  investigation  on  the  form  of  the  liga- 
ture that  the  modern  single  thread  found,  at  one  time,  almost  uni- 
versal adoption.  Cutting  short  both  ends  was  adopted  as  long  ago 
as  1798,  by  an  American  naval  surgeon,  and  by  Dr.  Maxwell,  of  Dum- 
fries; and  the  practice  was  followed  by  Hunter  and  other  military 
surgeons.     Hunter  also  suggested  the  use  of  the  hair  ligature. 

The  introduction  of  the  animal  ligature  is  generally  ascribed  to 
Physick,  whose  ligatures  were  made  of  chamois  leather,  rolled  on  a 
slab  to  make  them  hard  and  sound.  Sir  Astley  Cooper  tried  them, 
and  they  were  applied  in  this  country  to  all  the  large  vessels  by  Dr. 
Jamieson  of  Washington.  The  latter  advised  using  the  buckskin 
soft,  and  a  little  broader  than  the  thickness  of  the  skin.  With  the 
introduction  of  antiseptic  surgery  animal  ligatures  have  probably 
largely  superseded  all  other  methods  of  securing  vessels.  The 
mechanical  action  of  catgut,  kangaroo,  or  whale  tendon  upon  the 
vessel-wall  differs  little  from  that  produced  by  silk.  Barwell  has 
recently  proposed,  in  the  treatment  of  aneurism,  the  use  of  a  liga- 
ture which  need  not  ulcerate  through  the  artery,  thus  curing  aneur- 


40  TJie  Ligature  of  Arteries. 

ism  without  division  of  the  two  internal  coats.  His  flat  ox-aorta 
ligature  is  intended  to  act  in  this  way.  He  thinks  it  may  become 
organized,  having  seen  remains  inseparably  mixed  with  the  sur- 
rounding tissue  fifteen  months  after  it  had  been  applied.  In  other 
cases  it  is  absorbed.  It  is  interesting  to  note  that,  in  specimens 
where  the  ligature  had  been  thus  employed, — that  is,  when  the  intima 
had  not  been  injured  according  to  Mr.  Barwell, — clots  have  never 
been  found  to  exist.  Dent"°  reports  a  case  of  the  application  of  the 
tendon-ligature  to  the  carotid  and  subclavian,  followed  by  death  ten 
days  after  the  operation.  In  an  examination  of  the  carotid,  the 
knot  of  the  tendon-ligature  was  seen  in  close  contact,  encysted  in  a 
small  cavity  in  the  effused  lymph.  The  knot  was  almost  gelatinous 
in  appearance,  but  small  glistening  tendinous  bands  could  be  seen 
crossing  the  dark  space.  The  vessel  was  completely  occluded  for  a 
quarter  of  an  inch,  being  represented  by  a  cord  of  fibro-cellular 
tissue.  Transverse  sections  showed  that  the  external  coat  of  the 
artery  "was  not  ulcerated,"  and  this  condition  is  considered  to  be 
due  to  the  slight  swelling  and  softening  which  such  a  ligature  under- 
goes. New  blood-vessels  were  found  developed  in  those  parts  of  the 
tendon  which  lie  close  to  the  artery;  that  is,  rows  of  spindle-shuped 
cells,  with  spaces  between,  were  seen  branching  in  the  tendon-tissue, 
and  blood-vessels  were  seen,  passing  into  the  artery  and  tendon  both. 
The  ligature  was  also  infiltrated  in  other  portions  with  granulation 
cells.  Some  of  the  adjacent  muscular  coat  was  being  attacked  and 
eaten  away. 

Arnaud  ='■'  experimented  with  carbolized  catgut  on  the  femoral 
arteries  of  dogs;  at  the  end  of  four  days,  in  one  experiment,  no 
trace  of  the  catgut  could  be  discovered;  on  the  other  hand,  in  another 
experiment,  it  was  seen  slightly  altered  as  late  as  the  seventh  day. 

Lister,™  in  an  address  before  the  Clinical  Society  of  London, 
gives  the  following  example  of  the  dangers  attending  silk  or  hempen 
ligatures.  Six  hempen  ligatures  were  placed  upon  the  thyroid  vessel 
in  an  operation  for  the  removal  of  a  goitre;  and,  although  perfect 
asepsis  had  been  preserved,  they  all  came  away  at  the  end  of  one  to 
eight  months,  having  caused  the  formation  of  a  slight  amount  of  pus 
about  the  knots.  The  interstices  of  the  thread  were  loaded  with  a 
form  of  micrococcus  occurring  in  groups  of  two  or  three,  instead  of 
chains,  to  which  he  has  given  the  name  granuligera,  a  form  frequent 
in  antiseptic  wounds.  They  produce  an  acid  fermentation,  and,  in 
this  case,  the  acid  serum  became  a  source  of  irritation.  He  uses 
the  catgut  ligature,  as  at  present  prepared,  in  a  simple  reef-knot, 


History.  41 

tying  it  sufficiently  tight  to  cause  a  giving  way  of  the  internal  and 
middle  coats.  He  concedes  to  Mr.  Barwell  that  the  rupture  of  these 
coats  is  not  essential,  but  it  is  advantageous  "  by  leading  to  a  salu- 
tary corroborative  process  of  repair."  The  catgut  is  prepared  from 
the  sub-mucous  cellular  coat  of  the  intestine  of  the  sheep,  the  mus- 
cular and  mucous  coats  being  scraped  away.  It  is  then  steeped  in 
a  one  to  twenty  solution  of  carbolic  acid  mixed  with  a  weak  solution 
of  chromic  acid.  As  to  what  becomes  of  the  material,  he  says:  "  If 
it  has  not  been  properly  prepared,  the  substance  of  the  catgut  be- 
comes converted  in  the  course  of  a  very  few  days,  into  a  soft  pulta- 
ceous  mass,  which,  when  we  examine  it  by  a  microscope,  we  see 
consists  of  remains  of  the  old  cellular  tissue  of  the  submucous  coats, 
with  the  interstices  among  the  fibres  filled  with  cells  of  new  forma- 
tion. The  catgut-tissue  is  infiltrated  with  young  growing  cells,  and 
it  is  obvious  that  it  is  this  infiltration  which  is  the  cause  of  the  soften- 
ing; but,  on  the  other  hand,  if  the  catgut  is  properly  prepared,  in- 
stead of  being  infiltrated  by  the  cells  of  new  formation,  it  is  only 
superficially  eroded.  Until  nearly  a  fortnight  has  elapsed  erosion 
does  not  begin.  It  then  proceeds  gradually,  and  therefore  the 
thicker  the  catgut  the  longer  is  the  time  required  for  its  complete 
renewal.  We  may  fairly  consider  that  from  a  fortnight  to  nearly 
three  weeks  is  long  enough  for  the  persistence  of  a  ligature  upon 
an  artery  in  its  continuity."  The  specimen  of  so-called  organization 
of  the  ligature  upon  the  carotid  of  the  calf  in  which  "  ligatures  of 
new  formation  are  incorporated  with  the  external  coat  of  the  artery  " 
is  thus  explained.  The  catgut  does  not  come  to  life  again,  but,  as  in 
the  organization  of  the  blood  clot,  "  new  tissue  forms  at  the  expense 
of  the  old,  *  *  *  jjs  (-j^g  qJ(-]  tissue  is  absorbed  by  the  new, 
and,  *  *  *  ^5  ti-^g  q1(]  ig  absorbed,  new  is  put  down  in  its  place." 
Bruns  thinks  that  many  failures  quoted  by  him  are  due  to  the  fail- 
ure to  rupture  the  inner  coats,  and  the  consequent  absence  of  a  throm- 
bus. This  writer  recommends,  strongly,  a  temporary  ligature  passed 
through  a  fine  silver  tube,  and  removed  in  one,  two,  or  three  days. 
He  concedes,  however,  the  advantages  of  the  catgut  ligature.  He 
corroborates  Lister's  views  as  to  the  formation  of  new  tissue  in  the 
place  of  the  catgut,  and  sees  in  this  a  preservation  of  the  continuity 
of  the  vessel,  and  the  absence  of  the  undesirable  ulcerating  process 
produced  by  the  silk  ligature.  The  ordinary  silk  or  hempen  liga- 
ture, if  cut  short  in  wounds  treated  antiseptically,  is  rarely  seen  again, 
and  the  instances  are  too  frequent  to  specify,  where  careful  search 
has  failed  to  discover  them  in  the  newly  formed  tissue.     AViien  it  is 


42  The  Ligature  of  Arteries. 

necessary  to  apply  the  "mediate  ligature,"  as  on  the  pedicle  in 
ovariotomy,  its  greater  holding  power  gives  it  a  superiority  over  the 
catgut,  and  the  testimony  of  ovariotomists  as  to  its  influence  upon 
the  healing  process  is  not  unfavorable. 

Metallic  ligatures  have  not  been  favorably  received,  though  satis- 
factory results  have  been  obtained  from  their  use.  Holt,'^^  for  in- 
stance, has  used  a  number  of  wire  ligatures  in  the  same  wound,  the 
ends  being  cut  short,  and  the  wound  healing  by  first  intention;  nO' 
portion  coming  away.  Pollock  ''°  used  them  somewhat  like  the  acu- 
pressure needle  in  the  flaps  of  the  wound,  twisting  the  knot  on  the 
outside  of  the  skin.  They  were  left  in,  on  an  average,  five  and  a 
half  days,  with  good  results.  Holmes,  on  the  other  hand,  objected 
to  them  on  account  of  the  difficulty  of  regulating  the  tension  of  such 
a  ligature;  and  Simon,  of  Heidelberg,  also  complained  that  they 
caused  too  much  injury  to  the  vessel.  The  tolerance  of  the  tissues 
for  metallic  substances  left  permanently  in  bones,  or  in  the  pillars  of 
the  rings,  in  operations  for  hernia,  has  been  abundantly  testified  to. 

A  word  in  conclusion  upon  the  action  of  the  blood  in  coagulating 
in  arteries.  According  to  Conheim,  fibrine  is  formed  by  the  union 
of  two  fibrine-generators,  fibrinogen  and  paraglobulin  with  the  co- 
operation of  fibrine-ferment.  Fibrinogen  is  found  in  the  blood 
plasma,  while  the  fibrine-ferment  and  the  paraglobulin  are,  for  the 
most  part,  found  in  the  white  blood  corpuscles.  It  is  only  by  the 
breaking  down  of  the  latter  that  fibrine-ferment  and  the  paraglobulin 
are  set  free,  and  are  able  to  act  upon  the  fibrinogen.  So  long, 
therefore,  as  the  corpuscles  remain  intact,  coagulation  cannot  take 
place.  Physiologically,  we  have  an  occasional  breaking  down  of 
corpuscles,  but  the  living  wall  seems  to  possess  the  power  to  destroy 
the  small  quantities  of  fibrine-ferment.  Endothelium,  being  com- 
mon to  all  vessels  of  whatever  size,  is  probably  the  structure  which 
exerts  the  power  shown  by  the  vessel-wall  in  preventing  coagula- 
tion, so  long  as  it  remains  uninjured  and  performs  its  physiological 
functions.  If,  however,  this  cell  be  injured,  coagulation  will  take 
place.  The  thrombosis,  which  occurs  after  ligature,  depends  upon 
the  contact  of  the  blood  with  gn  injured  intima.  Virchow  thought 
that  a  slowing  or  stoppage  of  the  current  was  a  factor  in  coagulation, 
and  that  the  wall  could  prevent  coagulation  only  when  the  blood  was 
in  motion;  but  Baumgarten  has  shown  that  a  double  ligature  may  be 
placed  upon  a  vessel,  and  that  the  blood  included  will  still  remain 
fluid,  if  sufficient  precautions  have  been  taken  to  prevent  injury  to 
the   endothelium  during  the  operation.     Baumgarten  also  claimed 


History.  43 

that  thrombosis  did  not  occur  in  his  experiments  if  strict  asepsis  were 
preserved,  even  though  the  vessel-wall  was  uninjured.  In  the  so-called 
marasmic  thrombi  it  is  always  possible  to  demonstrate  a  defect  in 
the  endothelium  at  the  point  of  coagulation.  The  slowing  of  the 
current  favors  coagulation  only  when  we  have,  combined  with  it, 
some  such  defect  as  this.  Zahn  has  watched  the  development  of 
the  white  thrombus  in  the  tongue  of  a  curarized  frog.  If  a  crystal 
of  common  salt  be  placed  upon  a  vessel,  the  observer  will  notice, 
presently,  an  accumulation  of  white  corpuscles  at  the  corresponding 
point  on  the  inside.  A  clump  may  be  formed  by  the  addition  of 
more  corpuscles,  and,  if  this  be  washed  away  by  the  current,  a  second 
one  will  form  in  a  similar  way,  if  the  irritation  of  the  salt  continue. 
At  times,  the  irritation  may  be  so  great  as  to  collect  a  large  number 
of  corpuscles,  so  as  to  obstruct  the  vessel,  and,  in  that  case,  a  num- 
ber of  red  corpuscles  will  probably  be  found  imprisoned  in  the 
vessel.  Usually,  we  do  not  find  more  than  a  little  hill  of  white  cor- 
puscles at  the  affected  spot.  This  mass  subsequently  undergoes  a 
change  into  fine  granules,  and  shrinks  a  little;  while  the  cell  contours 
begin  to  disappear.  At  the  end  of  twenty-four  hours  the  cell  outline 
has  disappeared,  and  we  have  a  grayish,  granular,  semi-translucent 
mass  in  which  it  is  not  possible  to  demonstrate  nuclei  with  reagents. 
This  material  is  similar  to  the  tough  masses  of  fibrine  obtained  from 
blood  by  beating  it  with  a  stick,  which  affords  a  striking  example  of 
the  action  of  the  white  corpuscles  in  coagulation.  The  white  clot  is 
formed,  whenever  coagulation  takes  place  in  a  vessel,  where  the  cir- 
culation is  still  going  on  during  the  thrombus  formation.  All 
thrombi,  dependent  upon  changes  in  the  vessel-walls,  would  neces- 
sarily be  white;  as  would  also  a  thrombus  which  plugged  a  wound 
in  the  vessel-wall;  for,  in  this  case,  if  ever,  we  have  coagulation  with 
flowing  blood.  Where  red  corpuscles  are  found  in  considerable 
numbers  in  the  clot,  it  is  called  a  "  mixed  "  clot.  The  great  majority 
of  thrombi  are  either  "  white  "  or  "  mixed."  The  thrombus  may  be 
disposed  of  by  central  softening  or  by  organization.  The  greater 
portion  of  the  new  formation  comes  from  the  newly  formed  vessels 
developed  from  the  vasa  vasorum,  or  from  the  adventitia  and  sur- 
rounding connective  tissues.  It  is  not  probable  that  the  new  tissue 
is  formed  from  the  endothelium.  The  most  important  change  in 
the  new  tissue  is  its  contraction,  which,  since  it  is  unequal  at  differ- 
ent points,  forms  an  irregular  series  of  spaces  through  which  the 
blood  flows  as  through  a  sponge. 

A  brief  summary  is  given  by  Baumgarten  of  the  views  held  by 


44  TJi(^  Ligature  of  Ai't cries. 

previous  observers  on  the  question  of  the  formation  of  the  thrombus. 
Virchow  considered  that  it  was  caused  by  the  slowing  or  stoppage 
of  the  blood  current. 

Briicke  thought  the  wall  of  the  vessel  the  important  factor  in 
preserving  the  fluidity  of  the  blood. 

Durante  held  the  inflammatory  changes  in  the  endothelium  re- 
sponsible for  the  coagulation  of  the  blood. 

Szuman  attributed  it  to  injuries  of  the  intima. 

Baumgarten  found  that  a  single  or  a  double  ligature  could  be 
applied  without  the  formation  of  a  clot,  if  strict  asepsis  were  em- 
ployed. He  also  observed  in  the  umbilical  arteries  of  two  four 
weeks'  old  children,  fluid  blood,  or  blood  which  had  the  appearance 
of  being  coagulated  post  mortem.  He  therefore  does  not  regard 
the  stagnation  of  the  blood  as  a  cause  of  coagulation,  or  a  rupture 
or  a  growth  from  the  intima,  for  both  of  these  conditions  were  found 
in  his  experiments.  By  painting  croton  oil  on  the  piece  of  vessel 
included  between  two  ligatures,  he  was  able  to  produce  a  clot  at  this 
point;  but,  although  the  inflammation  continued  further  than  this 
limit,  no  coagulation  took  place  except  between  the  ligatures.  In- 
flammation of  the  wall  does  not  therefore  suffice,  he  thinks,  to  pro- 
duce coagulation. 

His  experiments,  he  says,  confirm  Virchow's  axiom  that  inflam- 
mation and  thrombosis  do  not  necessarily  go  together,  and,  he  adds, 
they  are  not  discordant  with  Briicke's  theory,  for,  according  to  the 
latter,  an  inflamed  part  does  not  necessarily  cease  to  perform  its  func- 
tions. If,  however,  the  inflammatory  condition  go  far  enough  to 
produce  a  necrosis,  the  blood  will  coagulate.  But,  inasmuch  as  we 
frequently  find  coagulated  blood  in  inflamed  vessels  in  which  the 
anatomical  evidence  of  necrosis  is  wanting,  as  in  operations  not 
carried  on  antiseptically,  we  must  assume  that  coagulation  takes 
place  by  an  interference  with  the  power  possessed  by  the  wall  to 
preserve  the  blood  in  its  integrity,  produced  either  by  a  total  de- 
struction, or  by  a  functional  impairment  of  the  tissues  of  the  wall; 
or,  secondly,  by  a  passage  through  the  wall  of  chemical  substances, 
which,  without  altering  the  structure,  may  set  in  operation  certain 
processes,  like  ferment-formation,  which  lead  to  coagulation.  The 
role  played  by  the  so-called  granule  masses,  granular  debris,  blut- 
plattchen  or  blood  plaques,  in  the  process  of  coagulation  is  at  pres- 
ent exciting  much  attention.  The  reader  is  referred  to  Osier's -^^ 
recent  lectures  upon  this  subject. 


History.  45 

MINUTE   ANATOMY    OF    THE    ARTERIES. 

According  to  Shakespeare, -'^  in  the  larger  arteries  in  the  adventitia 
there  is  a  net-work  of  branched  corpuscles  which  Hes  in  lymph  spaces 
formed  by  a  loose  reticulum  and  felt-work  of  white  fibrous  tissue. 
Between  it  and  the  media,  a  few  elastic  fibres,  collected  into  a  net- 
work, are  found  in  the  larger  vessels  of  this  class.  A  small  number 
of  elastic  fibres  constitute  the  elastic  layer  of  the  intima;  and  between 
this  layer  and  the  endothelium  are  a  small  number  of  branched  con- 
nective tissue-cells,  connected  together  into  a  membraneous  net- 
work. The  media  consists  of  a  continuous  muscular  membrane 
composed  of  a  single  layer  of  muscular  cells. 

In  larger  vessels  there  is  a  more  complete  development  of  the 
connective  tissue  felt-work,  whose  fibres  become  more  longitu- 
dinal; scattered  among  these  bundles,  a  few  fine  elastic  fibres  are 
found  and  also  connective  tissue  corpuscles  and  lymphoid  cells. 
These  loose  meshes  are  lymph-spaces.  The  elastic  fibres  be- 
come more  abundant,  and  larger  near  the  media,  and  they  here 
form  a  more  dense  net-work,  separating  the  adventitia  from  the 
media,  and  known  as  the  external  elastic  membranes;  The  media 
has  a  large  number  of  muscular  fibres,  the  cells  being  arranged 
in  transverse  bundles.  The  different  layers  are  separated  by 
plates  of  elastic  tissue  in  the  form  of  fenestrated  membranes, 
running  mainly  longitudinally,  connected  together  by  net-works  of 
fine  elastic  fibres.  A  small  amount  of  fibrous  connective  tissue  is 
formed  between  the  bundles.  At  the  external  boundary  of  the  in- 
tima is  another  dense  collection  of  elastic  tissue,  the  internal  elastic 
membranes  consisting  of  two  or  more  fenestrated  elastic  layers,  so 
closely  packed  against  each  other  as  to  present,  in  section,  an  ap- 
pearance of  a  structureless  membrane.  (According  to  Winiwarter, 
the  normal  intima  of  some  vessels  of  this  size,  as  the  tibial  artery, 
possesses  two  well-formed  laminae  with  an  intervening  fibrous  layer 
in  which  spindle  and  stellate  cells  are  found.)  On  the  internal  face 
of  the  elastic  membrane  is  a  slight  accumulation  of  white  fibrous 
tissue  arranged  longitudinally;  the  fibres  intercross,  however,  leav- 
ing lymph  spaces  between  them,  containing  fusiform  and  branched 
connective  tissue  corpuscles.  This  layer  is  covered  by  the  endothe- 
lium composed  of  lozenge-shaped  plates.  In  transverse  sections  the 
elastic  membrane  has  a  wavy  outline. 

In  the  larger  arteries  the  number  of  muscular  layers  is  increased, 
as  well  as  the  thickness  and  size  of  the  elastic  plates.     We  find,  in 


46  The  Ligature  of  Arteries. 

some  vessels,  longitudinal  and  oblique  bundles  of  muscle,  especially 
in  the  inner  portion  of  the  media.  They  are  also  found  in  the 
adventitia,  but  rarely  in  the  longitudinal  fibrous  layer  of  the  intima. 

(Thoma  has  observed  muscular  fibres  in  the  deeper  layer  of  the 
intima  of  the  aorta,  at  the  neighborhood  of  the  origin  of  the  great 
vessels  of  the  head  and  upper  extremities;  this  layer  bears  a  direct 
relation  to  the  branch.  Whether  these  cells  should  be  regarded  as 
part  of  the  intima  or  media  is  a  question;  they  are,  however,  inside 
the  elastic  lamina  which,  at  other  points,  is  the  line  of  demarcation 
between  the  intima  and  media.  These  fibres  are  sometimes  longitu- 
dinal, and  sometimes  transverse,  in  direction.  A  striking  example 
of  this  arrangement  is  seen  at  the  bifurcation  of  the  aorta,  where 
bundles  of  longitudinal  fibres  are  found  partly  in  the  intima,  and 
partly  in  the  media.  The  evident  intention  of  this  band  of  fibres  is 
to  support  the  spur,  formed  at  the  point  of  division,  against  the 
blood-stream.  In  a  less  pronounced  form,  they  are  to  be  found  at 
all  arterial  divisions.  He  finds  the  media  in  the  aorta  of  dogs  ex- 
ceedingly rich  in  muscular  fibre). 

The  elastic  lamina  of  the  larger  arteries  is  much  thicker,  and  is 
sometimes  laminated;  so  that  we  see,  apparently,  two  laminae  with 
a  small  amount  of  connective  tissue  between  them.  The  fibrous 
layer  of  the  intima  is  now  quite  distinct. 

The  muscular  cells  of  the  arteries  are,  in  the  main,  simple, 
smooth,  fusiform  cells  with  rod-shaped  nuclei.  In  the  larger  trunks 
the  ends  may  be  more  or  less  bifurcated,  or  even  branched.  In  the 
aorta,  flattened,  stellate,  muscular  cells  are  often  met  with. 

In  the  large  vessels,  the  outer  and  middle  coats  are  supplied  with 
blood-vessels,  the  vasa  vasorum.  In  a  few  instances,  capillary 
vessels  even  enter  the  tunica  intima. 


CHAPTER  II. 

EXPERIMENTS    ON    ANIMALS. 

A  CRITICAL  Study  of  the  investigations  on  the  nature  of  repair  in 
arteries  after  ligature,  leaves  one  strongly  impressed  with  the  fact, 
that  those  which  have  been  made  since  the  beginning  of  the  histo- 
logical era  have  been  conducted  chiefly  with  reference  to  their  bear- 
ing upon  prevailing  theories  of  the  day,  and  from  a  pathological, 
rather  than  from  a  surgical  standpoint.  The  history  of  this  research 
is,  in  fact,  a  history  of  the  rise  and  gradual  development  of  the 
science  of  cellular  pathology. 

Since  Hunter  first  enunciated  the  theory  of  the  organization  of 
the  thrombus,  this  field  has  been  a  favorite  one  on  which  to  test  the 
theory  of  cell  action,  advanced  successively  by  Schwann,  Virchow, 
Recklinghausen,  Conheim,  His,  and  others.  Investigation  has  been 
directed  to  the  action  of  the  white  corpuscle,  the  wandering  cell,  the 
connective  tissue  corpuscle,  and  the  endothelium;  the  early  changes 
which  occur  in  a  vessel  after  ligature  being  supposed  to  offer  special 
facilities  for  such  studies.  During  the  last  half  century,  surgeons 
have  been  content  to  leave  the  question  of  the  repair  of  blood- 
vessels mainly  in  the  hands  of  the  histologist,  and  the  more  purely 
surgical  aspects  of  the  question  have  remained  pretty  much  in  the 
condition  in  which  they  were  left  by  Jones.  It  is  for  the  purpose  of 
reviewing  the  whole  question  from  a  surgical  point  of  view  that  the 
following  series  of  investigations  has  been  conducted.  The  attempt 
is  here  made  to  trace  the  process  of  repair  from  the  earliest  visible 
change  to  the  development  of  a  tissue  which  is  incapable  of  further 
elaboration;  in  other  words,  to  the  permanent  cicatrix.  For  this  pur- 
pose a  series  of  experiments  has  been  performed  upon  dogs,  covering 
the  most  important  points,  and  ranging  in  time  from  a  few  hours  to 
four  months.  The  experiments  on  horses  were  made  chiefly  with  a 
view  to  obtain  specimens  suitable  for  macroscopic  study.  These 
investigations  have  paved  the  way  for  a  more  intelligent  study  of  a 
series  of  specimens  taken  from  the  human  subject,  embracing  liga- 
tures in  amputations,  as  well  as  those  made  in  continuity.  Finally, 
an  attempt  has  been  made  to  explain  the  dift'erences  found  in  the 
two  results  of  the  last  series,  by  a  comparison  with  the  changes  ob- 


48  The  Ligature  of  Arteries. 

served  in  the  obliteration  of  the  hypogastric  artery  and  the  ductus 
arteriosus  after  birth. 

In  many  of  the  experiments  about  to  be  described,  no  special 
attempt  was  made  to  keep  the  wound  in  an  aseptic  condition.  In 
the  case  of  ligature  of  the  carotid  artery,  a  compress  wet  with  car- 
bolized  water  was  tied  loosely  around  the  neck  beneath  the  collar; 
or,  if  the  wound  was  in  the  femoral  region,  no  dressing  at  all  was 
applied.  Cotton  sewing-thread  was  used  for  the  ligature,  and  for 
the  sutures. 

As  a  rule,  these  wounds  healed  rapidly  in  the  deeper  portions, 
but  a  small  subcutaneous  cavity  was  almost  invariably  found  con- 
taining serum,  muco-purulent  fluid,  or  pus,  as  the  case  might  be. 
Occasionally,  a  minute  fistulous  tract  communicated  from  this  sac 
with  the  ligature,  but  more  frequently  the  thread  was  completely 
encapsuled  in  the  surrounding  callus.  The  wound  through  the  skin 
had  generally  healed  by  first  intention.  In  a  few  cases  considerable 
suppuration  took  place,  and  in  one  instance  secondary  hemorrhage 
followed. 

DOGS. 
Femoral.     Two  Days. 

A  double  ligature  was  placed  upon  the  femoral  artery  of  a 
dog,  and  carmine  granules  were  freely  powdered  over  the  wound. 
The  animal  was  killed  in  forty-eight  hours,  and  the  specimen, 
after  being  hardened,  was  divided  longitudinally  into  halves.  The 
ligatures  were  placed  too  near  together  to  leave  a  space  of  sufificient 
size  for  the  purposes  intended  in  the  original  experiment,  but  the 
distal  portion  illustrates  very  beautifully  the  conditions  ordinarily 
produced  by  the  ligature  at  this  period.     (Fig.  i.) 

The  dense,  tendon-like  condition  of  the  adventitia  and  peri- 
adventitial  tissues  enclosed  in  the  ligature  is  well  shown.  A  mass 
of  cells  containing  carmine  granules  is  found  near  the  ligature, 
but  no  granules  are  found  within  the  vessel.  At  the  same  time  a 
number  of  granulation  cells  have  penetrated  the  almost  uninjured 
wall  of  the  vessel,  and  have  gained  access  to  the  interior.  None  of 
them,  however,  contain  carmine  granules,  which  are  found  in 
the  external  granulation  tissue.  The  thrombus,  which  is  slightly 
laminated,  contains  a  considerable  number  of  white  cells.  No  ap- 
parent change  has  taken  place  in  the  cells  of  the  intima.  The  liga- 
ture is  completely  covered  in  by  granulation  tissue. 


Experiments  on  Animals.  49 

Remarks. — This  specimen  shows  the  relations  of  the  parts  soon 
after  the  appUcation  of  the  ligature.  The  protective  influence 
against  hemorrhage  of  the  dense  external  wall  is  well  shown.  It  is 
also  an  illustration  of  the  much  disputed  statement  that  wandering 
cells  can  find  their  way  through  the  walls  of  a  vessel.  It  may  be 
said  that,  in  this  case,  the  walls  are  not  uninjured,  but  it  is  quite 
evident  that  we  have,  not  a  growth  of  granulation  tissue  through  a 
cleft  in  the  wall,  but  a  fair  example  of  what  wandering  cells  can 
accomplish. 

Femoral.     Eighty  Hours. 

The  femoral  artery  was  tied  with  a  cotton  ligature,  both  ends 
being  cut  short.  The  vein  was  adherent  to  the  vessel  opposite  the 
point  of  callus-formation.  The  specimen  was  divided  into  halves; 
longitudinal,  and  cross  sections  being  taken. 

Both  thrombi  are  well -developed,  but  the  usual  difference  in  size 
is  not  so  apparent.  The  media  is  not  curled  in,  but  has  been  cut 
completely  through.  The  ligature,  still  in  its  proper  place,  holds 
the  fibres  of  the  adventitia;  there  are  several  lateral  ruptures  of  the 
media  near  the  ligature,  to  which  points  the  thrombi  closely  adhere; 
elsewhere  they  have  separated  from  the  wall.  At  these  points  of 
attachment  the  staining  shows  the  growth  of  new  tissue  into  the 
thrombi,  and  the  amount  for  this  period  is  considerable.  A  study 
of  these  points  with  high  power  shows  the  lamina  ruptured  and 
reflected  back,  and  a  cell-growth  coming  from  the  inner  third  of  the 
media,  the  outer  portions  of  which  are  normal.  At  other  places, 
very  near  the  ligature,  where  the  thrombus  does  not  appear  to  be 
attached,  the  lamina  is  lifted  up,  pustule-like,  by  a  mass  of  young 
cells  lying  between  it  and  the  media;  and  there  are  other  similar 
cells  in  the  media  also,  but  they  are  very  few  in  number.  The  ad- 
ventitia is  infiltrated  with  round  cells.  The  intima,  at  some  distance 
away  from  the  ligature,  is  normal;  near  that  point  there  is  prolifera- 
tion of  its  cells,  forming  two  or  three  layers  of  spindle-cells,  min- 
gled with  round  cells,  which,  when  in  contact  with  the  clot,  project 
into  it,  at  times,  at  right  angles  to  the  wall.  An  examination  of  the 
thrombus,  by  picking  it  apart  with  needles,  shows  a  spindle-cell  and 
anastomosing  stellate  cell  reticulum  in  certain  portions. 

Remarks. — This  specimen  shows  that,  where  the  rupture  in  the 
elastic  lamina  has  occurred,  the  clot  is  most  adherent  and  the  cell- 
growth  most  active.  No  real  union,  however,  has  yet  taken  place; 
the  cell-growth  simply  holds  and  strengthens  the  clot,  replacing 
4 


50  TJic  Ligature  of  Arteries. 

some  of  its  old  substances  with  young  cells.  New  cells  do  not  come 
solely  from  the  intima,  but  are  noticeably  more  numerous  where  that 
layer  has  been  broken  through  and  the  media  exposed. 

Carotid.     Four  Days. 

The  left  carotid  of  a  large  dog  was  tied  with  a  silk  ligature,  both 
ends  of  which  were  cut  short.  The  animal  was  killed  at  the  end  of 
four  days.  A  longitudinal  section  showed  a  large  proximal  throm- 
bus, the  distal  thrombus,  if  any  existed,  having  disappeared. 

The  walls  of  the  proximal  portion  are  much  distended  by  the 
clot,  and  consequently  are  thinner  than  normal,  and  much  com- 
pressed. The  rupture  has  extended  through  three  quarters  of  the 
media,  the  ends  of  which  are  frayed  and  turned  in  toward  the  clot. 
Connected  with  this  wounded  surface,  which  constitutes  a  small 
gaping  wound  at  the  fundus  of  the  cul-de-sac  (Fig.  2)  formed  by 
the  proximal  end  of  the  vessel,  we  find  a  ramifying  net-work  of  fibres 
and  round  cells,  which  extends  for  some  distance  into  the  thrombus, 
but  is  most  abundant  near  the  wounded  surface;  it  comes  in  contact 
with  the  inner  wall  at  one  or  two  other  uninjured  points,  however. 
It  takes  staining  readily,  and  has  the  appearance  of  young  growing 
tissue.  There  is  no  infiltration  of  the  media  with  wandering  cells. 
No  change  is  to  be  detected  in  the  endothelial  layer.  The  ligature 
is  unaltered,  and  includes  the  fibres  of  the  adventitia  in  a  dense, 
transparent,  almost  homogeneous  bundle.  It  is  surrounded  by  a 
growth  of  small  round  cells  which  occupy  the  periadventitial  tissue 
for  some  distance  above  and  below  the  point  of  ligature.  Cross 
sections  show  that,  near  the  ligature,  the  cells  have  penetrated  into 
the  inner  layers  of  the  media. 

In  the  distal  portion,  the  media  is  ruptured  and  thrown  into 
longitudinal  folds.  There  is  no  infiltration  of  the  walls  with  round 
cells.  The  most  noticeable  point  is  the  endothelium,  which  is  in  a 
state  of  proliferation.  (Fig.  3.)  A  high  power  shows  a  number  of 
spindle-cells  disposed  in  no  regular  order,  hanging  generally  by  one 
extremity  to  the  wall,  or  interlacing  one  another,  and  also  stellate 
cells,  and  mother  cells  containing  numerous  nuclei. 

Remarks. — The  apparent  new  growth  of  young  tissue  to  be  found 
in  the  proximal  thrombus  consists  of  cells  resembling  white  corpus- 
cles and  fibres  of  coagulated  fibrine.  The  cells  are  probably,  chiefly 
the  white  corpuscles  of  the  clot,  which  accumulated  during  the 
process  of  coagulation.  It  seems  probable  that  a  few  cells  may  have 
wandered  into  the  clot  from  the  exposed  deeper  layer  of  the  media; 


Expcriuioits  on  Animals.  51 

and  possibly,  a  few  came  from  the  adventitia.  The  endothelium  is 
firmly  compressed  by  the  thrombus,  and  gives  no  evidence  of  any 
change.  In  the  distal  portion,  however,  where  no  thrombus  was 
seen,  it  having  probably  been  lost  in  the  preparation,  a  distinct 
proliferation  of  the  cells  of  the  intima  is  observed. 

Carotid.     One  Week. 

A  cotton  thread  ligature  was  passed  around  the  right  carotid, 
and  cut  short.  There  was  a  slight  collection  of  sero-purulent  ma- 
terial beneath  the  wound  in  the  skin  which  had  united  by  first  in- 
tention. The  ends  of  the  vessel  were  imbedded  in  a  well  formed  cal- 
lus, in  which  only  a  few  traces  of  the  ligature  could  be  found.  The 
thrombi  were  about  one  half  an  inch  in  length,  although  the  proxi- 
mal thrombus  was  a  little  the  shorter  of  the  two,  but,  as  usual,  con- 
siderably broader.  They  were  slightly  laminated  in  the  portions 
near  the  apex  of  the  clots: 

Proximal  End. — The  thrombus  is  firmly  attached  at  its  base,  and 
loosely  at  its  apex.  It  is,  at  points,  pervaded  with  anastomosing 
masses  of  protoplasm  with  ill-defined  structure.  At  others,  a  round 
cell-accumulation  is  seen  at  the  sides  of  the  clot.  Near  its  apex,  the 
clot,  which  has  here  shrunk  away  from  the  wall  of  the  vessel,  is  still 
attached  to  columnar  anastomosing  masses  of  young  cells.  This 
growth  consists  of  round  and  spindle-shaped  cells.  x'\lthough  they 
apparently  originate  from  the  intima,  an  inspection  with  high  power 
shows  rents  in  the  lamina  (Fig.  6)  through  which  some  of  the  cells 
have  evidently  grown.  The  other  portions  of  the  intima  which  are 
visible,  show  a  slight  thickening  of  its  layer  of  cells,  which  are  round 
and  spindle-shaped.  At  the  point  of  ligature,  the  walls  of  the  vessel 
are  slightly  retracted,  and  granulations  are  beginning  to  grow  into 
the  thrombus. 

Distal  Etui. — Here,  also,  the  walls  have  retracted,  and  the 
thrombus  is  invaded  by  granulations.  The  thrombus  is  narrow,  and 
loosely  attached  to  the  sides  of  the  contracted  vessel;  and,  where 
it  has  separated,  an  increase  in  the  cells  of  the  endothelial  layer 
may  be  seen.  At  one  or  two  points,  ornamental  festoons  of  spindle- 
shaped  cells  have  been  frayed  out  from  the  wall  by  the  contracting 
clot.  At  the  apex  of  the  thrombus,  there  is  an  accumulation  of  round 
cells.  Near  the  ligature,  the  clot  is,  in  places,  separated  from  the 
wall  by  fluid  blood. 

Remarks. — We  have  here  a  somewhat  earlier  invasion  than  usual 
of  the  lumen  of  the  vessel  by  granulation  tissue.     The  growth  of 


52  TJic  Ligature  of  Arteries. 

cells  from  the  inner  walls  of  the  vessel  has,  in  places,  permeated 
the  clot  for  some  little  distance,  and  serves  to  hold  it  firmly  in  place. 
This  is  particularly  noticeable  near  the  apices  of  the  thrombi.  Much 
of  the  cell-growth,  which  appears  to  spring  from  the  intima,  is  found 
to  project,  through  ruptures  in  the  elastica,  from  the  media. 

A  series  of  arteries  were  tied  with  special  reference  to  antiseptic 
precautions,  and  their  influence  upon  the  formation  of  the  throm- 
bus. All  details  of  the  antiseptic  treatment  were  rigidly  adhered  to. 
A  powerful  double-nozzle  carbolic  steam-spray  was  used.  The  hair 
was  shaved,  and  the  skin  washed  with  one-to-forty  carbolic  wash. 
All  instruments  were  placed  in  carbolized  water.  Chromicized  cat- 
gut was  used  chiefly  as  ligatures;  but  cotton  thread  was  occasionally 
substituted.  The  dressing  consisted  of  an  application  of  iodoform 
powder,  over  which  was  placed  a  thick  layer  of  borated  cotton, 
which  was  held  in  place  by  a  bandage  soaked  previously  in  car- 
bolized water.  The  dressing  was  not  changed,  but  iodoform  was 
powdered  on  freely  around  the  edges  daily.  No  difficulty  was  found 
in  keeping  a  dressing  over  the  carotid  or  femoral  arteries  for  a  whole 
week,  without  change. 

The  following  cases  are  selected  from  a  large  number,  for  the 
purpose  of  illustrating  this  point: 

Carotid.     One  Week. 

The  common  carotid  was  tied  at  about  the  middle  of  its  trunk 
with  catgut.  On  opening  the  vessel  above  and  below  this  point, 
no  thrombus  was  at  first  seen,  but,  after  laying  open  each  end  of 
the  vessel  to  the  exact  point  of  ligature,  two  very  minute  thrombi 
were  observed  which  might  easily  have  been  overlooked.  The 
callus  was  not  so  large  as  in  non-antiseptic  cases.  In  a  second 
case,  the  catgut  was  placed  very  gently  around  the  artery  so  as  to 
close  the  lumen,  if  possible,  without  doing  injury  to  the  walls. 
Complete  union  by  first  intention  took  place  in  the  wound.  On  dis- 
secting out  the  vessel,  it  was  apparent  that  the  callus  was  exceed- 
ingly small,  being  barely  sufficient  to  cover  in  the  ligature.  On 
opening  the  vessel  carefully  with  fine  microscope-scissors  no  throm- 
bus was  found;  but,  on  exploring  with  the  finest  bristle,  it  was  dis- 
covered that  the  lumen  had  not  been  obliterated,  and  the  blood  still 
flowed  through  the  ligatured  point.  Cross  sections  of  this  portion 
of  the  vessel  were  made  for  microscopic  study,  and  disclosed  the  fact 
that,  although  the  walls  of  the  vessel  had  not  been  accurately  approxi- 


Expcriuioits  on  Animals.  53 

mated,  a  number  of  ruptures  through  the  elastic  lamina  had  taken 
place,  and,  from  these  points,  granulations  were  sprouting  into  the 
lumen  of  the  vessel.  In  still  another  case,  a  cotton  thread  was  tied 
around  the  femoral  artery.  The  wound  healed  throughout  by  first 
intention.  The  callus  was  of  about  the  size  observed  in  cases  oper- 
ated upon  without  special  antiseptic  precautions.  To  make  sure 
that  the  vessel-lumen  was  completely  obliterated  by  the  ligature, 
water  was  injected  into  one  end  with  a  fine  syringe,  but  it  failed  to 
pass  through.  On  laying  open  the  vessel  a  minute  thrombus  was 
found  at  each  end,  the  proximal  being  slightly  the  larger.  Each  was 
about  the  size  of  mustard  seed.* 

Carotid  and  Femoral.     Nine  Days. 

The  carotid  and  femoral  of  a  medium-sized  dog  were  tied  with 
cotton  ligatures  without  special  antiseptic  precautions:  the  ends 
were  cut  short,  and  the  animal  was  killed  on  the  ninth  day.  The 
ends  of  the  carotid  were  separated  from  one  another  about  one 
third  of  an  inch,  the  knot  still  being  attached  to  the  distal  portion; 
the  two  ends  being  enclosed  in  a  mass  of  inflammatory  tissue.  A 
longitudinal  section  divided  the  specimen  into  halves. 

The  chief  point  of  interest  is  the  shape  of  the  proximal  thrombus, 
which  is  about  a  quarter  of  an  inch  in  length,  and  resembles  a  polyp 
attached  by  a  slender  stem  to  the  end  of  the  stump  of  the  vessel 
inside.  It  has  a  twisted  appearance,  as  if  in  a  more  plastic  state,  it 
had  been  twirled  about  on  its  own  axis  by  the  motion  of  the  blood. 
Surrounding  the  stem  is  a  clear  homogeneous  blood-clot,  in  which 
cell-growth  can  be  readily  studied.  At  the  bottom  of  its  cup-shaped 
cavity,  which  is  lined  with  frayed  and  bruised  portions  of  the  media, 
there  is  a  slight  growth  of  delicate  anastomosing  stellate  and  spindle- 
cells  with  prolongations,  making  a  reticulum  of  web-like  structure,  in 
the  meshes  of  which  red  corpuscles  are  lying.  This  tissue  is  attached 
to  adjacent  fibres  of  the  media,  which  is  considerably  altered  and  in- 
filtrated with  inflammatory  cells.  A  little  higher  up  the  cell-growth 
is  more  voluminous,  and  the  delicate  mesh-work  is  obscured  by 
masses  of  young  cells.    Occasionally  columnar  shaped  masses  of  cells 

*  Circumference  of  vessel  inside  above  proximal  thrombus,  3.40  mm. 
Diameter  of  vessel  therefore,  about .  ....  i.oS  mm. 
Proximal  Thrombus,  length     .         .         .         .         .         .1.61  mm. 

breadth 0.65  mm. 

Distal  Thrombus,  length 1.49  mm. 

width 0.56  mm. 


54  TJic  Ligature  of  Arteries. 

are  seen  extending  some  distance  into  the  transparent  clot.  A  little 
higher  up,  the  intima  is  found  slightly  thickened,  and  a  few  spindle 
and  stellate  cells  are  seen  projecting  into  the  clot  from  this  layer. 
The  thrombus  is  attached  by  its  stem  to  the  delicate  anastomosing 
cell  net-work  just  mentioned,  and  elsewhere  unattached,  except  at 
one  point,  where  it  appears  to  lean  against  the  wall;  it  is  composed 
of  red  corpuscles  and  fibres  of  fibrine  and  also  of  a  cell-growth,  which 
readily  takes  the  coloring  matter  used:  this  new  tissue,  if  such  it  be, 
is  arranged  in  columnar-shaped  masses. 

The  distal  portion  is  still  surrounded  by  the  adventitia  which  is 
held  by  the  ligature,  but,  at  one  point,  there  is  a  slight  rent  through 
which  some  granulation-cells  are  pushing  their  way.  The  lumen 
is  occupied  by  a  transparent  homogeneous  clot,  into  which  we  find, 
near  the  end  of  the  vessel,  a  moderate  number  of  round  spindle-cells 
growing;  and,  at  points  where  the  media  has  been  lacerated,  colum- 
nar or  granulation-like  masses  of  cells  are  seen.  The  intima  shows 
here  and  there,  a  slight  activity,  and  some  of  the  cells  are  evidently 
produced  by  this  layer;  but,  as  a  whole,  the  cell-growth  is  slight  in 
amount  in  the  distal  end. 

Remarks. — This  specimen  is  of  interest  on  account  of  the  trans- 
parency of  the  clot  and  the  period  of  organization  of  the  cicatrix. 
The  granulation  tissue  has  not  yet  penetrated  the  vessel  to  any  great 
extent,  although  the  walls  of  the  proximal  end  are  infiltrated  with 
granulation-cells.  The  delicate  cell  growth  in  the  interior  is  limited 
in  amount.  The  columnar  masses  of  cells  appear  to  originate  from 
the  granulation  tissue. 

The  thread  at  the  time  of  ligature  had  cut  its  way  so  nearly 
through  the  femoral  artery,  that  the  walls  had  been  severed,  and  a 
clot  had  formed  between  the  ends. 

The  walls  of  the  proximal  ends  have  contracted,  and  an  abundance 
of  granulation  tissue  has  growm  into  the  thrombus,  which  is  a  large 
one.  The  granulations  have  taken  the  columnar  form.  In  the  peri- 
pheral end  the  clot  is  not  present,  and  there  exists  a  growth  of  a 
pyramidal  shape  composed  of  columnar  masses  of  cells  intertwining 
in  such  a  way  as  to  produce  spongy,  or  cavernous,  tissue.  (Fig.  8.) 
This  tissue  appears  to  spring  from  a  cleft  in  the  coats  of  the  vessel 
at  the  point  of  ligature.  It  is  composed  largely  of  round  cells,  but 
both  the  spindle  and  stellate  forms  are  found. 

There  is  a  slight  proliferation  of  the  endothelium, spindle  and  round 
cells  being  found  in  this  layer.  The  walls  of  the  vessel,  in  the  immedi- 
ate neighborhood  of  the  thread,  are  much  infiltrated  with  round  cells. 


Experiments  on  Animals.  55 

Remarks. — We  have  here  an  example  of  the  tissue  which  displaces 
the  blood  clot,  and  an  indication  of  the  way  in  which  it  acquires  its 
peculiar  cavernous  character:  we  see  also  its  origin  from  tissue 
which  has  penetrated  the  open  end  of  the  vessel. 

Femoral.     Ten  Days. 

A  single  cotton  thread  was  applied  to  the  femoral  artery,  and 
cut  short.  A  well-marked  callus  was  found.  On  laying  open  the 
specimen  by  a  longitudinal  incision,  the  ends  of  the  vessel  were 
found  retracted  some  distance  from  each  other,  the  ligature  re- 
maining in  contact  with  the  distal  end. 

The  proximal  end  has  apparently  cicatrized,  the  ends  of  the  media 
being  in  close  apposition,  and  apparently  forming  a  perfect  cul-de- 
sac.  Longitudinal  sections  show  the  thrombus  lightly  attached  by 
a  pedicle  to  the  fundus  of  this  sac.  (Fig.  9.)  It  has  a  polypoid 
shape,  and  is  surrounded*  by  an  unstratified  fresh  clot.  The  intima 
is  not  obscured  by  thrombus,  and  can  be  conveniently  studied.  At 
the  line  of  union  of  the  two  sides  of  the  media  the  cells  of  the  endo- 
thelium have  proliferated,  and  formed  a  thickened  layer.  (Fig.  7.) 
At  some  points,  where  there  is  a  slight,  excavated  wound  the  cells  had 
grown  down,  and  across,  the  depression.      (Fig.  10.) 

The  media,  on  close  inspection,  is  found  infiltrated  with  wander- 
ing cells  on  either  side  of  the  point  of  ligature,  but  these  cells  have 
not  yet  reached  the  interior.     (Fig.  9.) 

The  distal  portion  has  retracted  considerably  and  its  walls  have 
separated,  giving  an  opportunity  for  the  granulation  tissue,  which 
surrounds  the  still  unabsorbed  ligature,  to  grow  freely  into  its  lumen. 

Remarks. — The  appearance  of  the  proximal  portion  in  this  speci- 
men is  instructive  as  showing  the  condition  of  supposed  union  by 
first  intention,  but  a  critical  examination  shows  that  only  the  first 
stage  of  the  healing  process  has  been  completed,  and  that  the  infiltra- 
tion and  absorption  of  the  ends  of  the  media  (now  apparently  united) 
are  just  beginning.  It  also  shows  that  the  endothelium  is  capable 
of  proliferation  and  of  taking  part  in  the  healing  process,  but  that 
the  amount  of  tissue  produced  by  this  layer  is  comparatively  insig- 
nificant. 

In  a  second  specimen  of  ten  days'  repair,  the  artery,  the  carotid, 
had  a  large  proximal  thrombus  with  a  small  extravasation  at  the  site 
of  the  ligature.  The  vessel  presented  the  appearance  of  the  so-called 
"ampulla-like  dilatation."  The  coats  of  the  artery  are  placed  up- 
on the  stretch,  and  the  media  is  correspondingly  narrowed.     (Fig.  2.) 


56  The  Ligature  of  Arteries. 

There  is  no  sign  of  a  proliferation  of  the  cells  of  the  intima,  but 
granulation-cells  are  penetrating  the  thrombus  at  the  point  of  liga- 
ture. The  distal  thrombus  is  thin,  and  has  shrunk  from  the  walls  of 
the  vessel,  where  a  considerable  activity  of  the  cells  of  the  intima 
can  be  seen.  There  is  also  some  penetration  of  granulation-cells  at 
the  point  of  ligature. 

Remarks. — This  specimen  presents  more  accurately  the  aveiage 
condition  of  the  process  of  repair  at  this  period.  The  walls  are 
beginning  to  retract,  and  the  granulation  tissue  to  invade  the  thrombi. 
It  is  worthy  of  note  that,  when  the  clot  is  firmly  wedged  in,  as  in 
the  case  of  the  proximal  clot,  there  is  no  growth  of  cells  of  the  intima; 
but  when  the  clot  is  less  intimately  in  contact  with  the  vessel-wall, 
more  or  less  activity  is  to  be  noticed  in  the  cells  of  this  layer. 

A  critical  study  of  these  specimens  shows  that,  up  to  this  period, 
the  walls  of  the  vessels  have  been  kept  in  contact  at  each  end,  but 
that  the  two  ends  have  begun  to  separate  from  one  another,  the  liga- 
ture either  having  been  disintegrated,  or  cast  off,  or  left  attached  to 
one  of  the  ends. 

At  or  later  than  this  time,  the  ends  of  the  vessel  begin  to  open 
by  a  retraction  of  the  vessels,  now  freed  from  the  ligature,  and  granu- 
lations begin  to  grow  into  the  thrombus  at  these  points. 

In  some  cases,  at  points  favorable  for  observation  a  slight  prolif- 
eration of  the  cells  of  the  intima  appears  to  have  taken  place,  but 
the  amount  of  this  growth  is  small,  and  difificult  to  find.  In  several 
instances  a  distinct  immigration  of  wandering  cells  was  observed, 
establishing  beyond  a  doubt  that  this  much  disputed  action  of  these 
cells  does  occur,  but  the  total  amount  of  cells  collected  in  this  way, 
in  the  interior  of  the  vessel,  is  small.  It  is  evidently  the  beginning 
of  a  process,  which  eventually  ends  in  an  absorption  of  the  edges  of 
the  vessel-walls  and  brings  about  their  retraction,  thus  giving  ingress 
to  larger  masses  of  granulation  cells. 

The  adventitia,  which  is  not  ruptured  by  the  ligature,  is  collected 
into  a  bundle  of  dense  fibres,  and  forms  a  tendinous  band,  holding 
the  two  ends  together:  this  band  is  eventually  permeated  and  disin- 
tegrated by  the  granulation  cells,  allowing  the  two  ends  to  retract 
from  one  another.  Granulation  tissue  has  accumulated  in  considera- 
ble quantity  around  the  ligature,  and  varies  in  quantity  with  the 
amount  of  inflammation.  It  forms  a  callus  in  which  the  two  ends  of 
the  vessel  are  imbedded  like  the  fragments  of  long  bones  after  frac- 
ture.    Even  in  cases  where  the  strictest  antiseptic  precautions  have 


Experiments  on  Anhnah.  57 

reduced   the   inflammatory  reaction  to  a  minimum,  this  callus-like 
mass  of  tissue  is  found. 

When  the  inflammation  has  been  great,  it  may  assume  considera- 
ble proportions;  but  in  cases  of  suppuration  and  hemorrhage  it  will, 
on  the  other  hand,  be  found  to  have  broken  down  and  to  have  left 
the  artery  more  or  less  exposed. 

The  thrombus  varies  greatly  in  size.  In  the  antiseptic  cases  it 
has  been  reduced  to  an  exceedingly  small  mass,  so  small  as  to  be 
easily  overlooked;  but  in  no  case  has  it  been  absent  entirely.  Like 
the  external  callus  it  appears  to  indicate  the  amount  of  traumatism 
which  has  been  produced,  but  not,  however,  with  the  same  accuracy, 
for,  in  some  of  the  most  perfect  examples  of  asepsis,  it  was  larger 
than  in  cases  in  which  this  treatment  had  been  less  successfully 
carried  out.  A  series  of  experiments  with  the  double  ligature,  per- 
formed to  test  the  question  of  the  activity  of  the  endothelium  and 
wandering  cells,  is  inserted  here,  to  preserve  as  nearly  as  possible  a 
chronological  order. 

DOUBLE    LIGATURE. 
One  Week. 

The  femorals  of  a  large  dog  were  exposed  at  two  points,  each 
about  one  inch  apart.  The  sheath  was  opened  only  at  the  point 
where  the  ligature  was  applied:  carmine  granules  were  then  freely 
sprinkled  on  the  wound.  No  attempt  at  an  antiseptic  dressing 
was  made.  The  intermediate  portion  was  compressed  so  as  to 
empty  it  of  blood,  but  in  one  case  the  attempt  was  only  partially 
successful.  There  was  a  suppurating  wound  beneath  the  sutures, 
at  the  end  of  a  week,  when  the  animal  was  destroyed,  and  in  bring- 
ing the  body  into  the  laboratory  on  that  day,  a  hemorrhage  took 
place  from  the  left  femoral  at  its  central  portion.  A  part  of  the 
vessel  which  included  the  ligatures  was  removed,  cut  in  halves,  and 
each  half  split  longitudinally. 

At  the  proximal  end,  from  which  the  bleeding  took  place,  a  fresh 
clot  is  seen  occupying  its  mouth.  This  clot  is  concave  on  its  inner 
surface  which  is  covered  b)^  white  corpuscles.  The  anterior  lip  of  the 
vessel  is  everted.  The  ligature  was  found  in  the  secretions  of  the 
wound.  There  is  no  clot  in  the  middle  portion,  the  ends  of  which 
are  slightly  separated,  admitting  the  entrance  of  granulation  tissue 
for  a  short  distance.  There  is  a  purulent  infiltration  of  the  media, 
which  has  separated  it  partially  from  the  adventitia,  but  only  a  very 


58  The  Ligature  of  Artej-ies. 

few  cells  have  found  their  way  through  the  coats  of  the  vessel  into 
the  interior.  There  is  no  trace  of  endothelium.  One  or  two  gran- 
ules of  carmine  are  seen  in  the  granulations  at  one  end,  but  most 
of  them  have  accumulated  in  the  upper  la3?ers  of  the  granulation 
tissue  forming  the  wound.  The  right  femoral  has  considerable  clot 
in  the  middle  portion.  The  media  is  infiltrated  in  its  outer  half  with 
cells,  and  some  of  these  appear  to  have  penetrated  through  the  walls. 
There  is  an  appreciable  growth  of  endothelium:  at  one  or  two  points 
collections  of  round  cells  are  seen,  which  might  have  been  the  result 
of  proliferation  of  the  cells  of  the  intima.  Each  end  of  this  portion 
is  slightly  opened,  and  occupied  by  a  mass  of  granulation  tissue. 
The  carmine  granules  are,  as  in  the  other  case,  upon  the  surface  of 
the  wound. 

Remarks: — In  both  of  these  vessels  the  ends  of  the  isolated  por- 
tions were  opened  somewhat  prematurely  by  the  suppurative  pro- 
cess; and  the  chief  supply  of  cells  found  in  this  portion  came  from 
the  granulations  which  forced  their  way  in  at  the  end,  and  not  from 
cells  wandering  through  the  coats  of  the  vessel  (although  a  vigorous 
attempt  was  being  made  to  penetrate  them),  nor  from  the  endothe- 
lium. In  one  case  no  change  in  that  layer  was  found,  and  in  the 
other  a  slight  proliferation  at  one  or  two  points.  Care  had  been 
taken  to  preserve  the  vitality  of  the  endothelium  by  leaving  the  walls 
of  the  vessels  as  much  as  possible  in  connection  with  the  sheath. 

DOUBLE   LIGATURE. 

One  Week, 

The  following  experiment  on  the  femoral  artery  is  recorded, 
as  the  operation  was  performed  under  the  strictest  antiseptic  pre- 
cautions. Care  was  also  taken  to  avoid  injury  to  the  walls  of  the 
middle  portion,  and  not  to  interfere  with  their  vascular  connec- 
tion with  the  vasa  vasorum  by  a  separation  of  this  portion  from 
its  sheath.  The  proximal  ligature  was  applied  first,  and  the  vessel 
gently  compressed  while  the  distal  ligature  was  tied,  so  that  as  little 
blood  as  possible  should  remain  between  the  two  ligatures.  The 
wound  healed  by  first  intention.  On  opening  the  specimen  a  small 
thrombus  was  found  between  the  two  ligatures  (No.  one  chromicized 
gut),  and  two  small  thrombi  about  one  sixteenth  of  an  inch  in  length 
were  found  at  the  distal  and  proximal  ends  respectively;  the  latter 
being  slightly  the  larger  of  the  two.  A  moderate  callus  surrounded 
each  ligatured  point. 


Experiments  on  Animals.  59 

Middle  Portion. — The  thrombus  is  small,  and  the  lumen  partially 
collapsed.  Along  the  inner  walls,  at  intervals,  there  is  a  formation 
of  spindle-shaped  cells,  slight  in  thickness,  hardly  more  than  a  sin- 
gle layer.  At  other  points,  there  is  an  endothelium  of  cube-shaped 
cells,  such  as  are  described  by  Baumgarten.  There  are  a  number 
of  ruptures  in  the  lamina  elastica,  and  cells  appear  to  be  growing 
through  these  spots  from  the  media  (somewhat  similar  to  the  growth 
in  Y\g.  6).  The  ends  of  this  portion  are  surrounded  with  granulation 
tissue,  and  the  walls  at  this  point,  though  still  loosely  in  contact,  are 
infdtrated  with  round  cells,  which,  at  one  point,  have  just  begun  to 
push  their  way  into  the  lumen. 

Distal  End.- — The  walls  have  slightly  retracted  here,  owing  to  a 
disintegration  and  yielding  of  the  catgut,  and  granulation  tissue 
presents  at  the  opening,  at  one  side  of  w4iich  the  thrombus  remains 
attached.  No  change  is  observed  in  the  intima.  The  ends  of  the 
media  are  slightly  infiltrated  with  round  cells. 

Froxi/nal  End. — The  thrombus  is  polypoid  in  shape,  and  attached 
to  a  fragment  of  the  vessel-wall  (as  in  Fig.  9).  No  endothelial 
growth  is  seen,  and  only  a  slight  infiltration  of  the  ends  of  the  media. 
Granulation  tissue  has  grown  in  between  the  proximal  end  and  the 
middle  portion,  and  the  fibres  of  the  catgut  are  thoroughly  infiltrated 
with  wandering  cells. 

Remarks. — In  this  experiment  no  wandering  of  cells  is  observed 
through  the  walls  of  the  isolated  portion  of  the  vessel.  There  is  a  slight 
proliferation  of  the  endothelium,  and  a  growth  of  cells  from  the  media 
through  ruptures  of  the  inner  wall.  Granulation  cells  are  apparently 
working  their  way  through  the  ends  of  this  portion  of  the  vessel,  and 
at  one  spot  have  penetrated  to  the  interior. 

DOUBLE  LIGATURE. 

Fourteen  Days. 

The  left  femoral  of  a  large  dog  was  tied  with  two  cotton  ligatures 
one  third  of  an  inch  apart;  and  the  animal  was  killed  at  the  end  of 
fourteen  days.  The  external  wound  had  healed  well,  but  a  wound 
was  found  below  the  surface  containing  pus,  and  the  remains  of 
the  ligatures.  Underneath  this  minute  abscess  lay  the  granula- 
tion tissue  which  enclosed  the  vessel.  A  longitudinal  section  shows 
the  proximal  thrombus  shorter  than  usual  owing  to  the  presence  of 
a  branch  a  short  distance  above  the  point  of  ligature.  The  central 
portion  is  collapsed   and  contains   traces   only   of  clot;    the    distal 


6o  The  Ligature  of  Arteries. 

portion  has  a  well-formed  thrombus;  no  traces  of  the  threads  exist 
at  the  ligatured  points. 

Proximal  Portion. — The  walls  of  the  vessel  have  separated  and 
very  typical  granulations  are  growing  into  the  deeper  layers  of  the 
clot,  which  they  have,  in  a  measure,  replaced.  The  cells,  of  which 
this  tissue  is  composed,  are  round  and  spindle-shaped  with  a  hyaline 
intercellular  substance,  and  the  borders  of  the  granulations  are  lined 
with  spindle-cells.  The  granulations,  being  crowded  close  together 
and,  overlapping  one  another,  form  a  papillary  growth,  and  between 
them  enclose,  consequently,  an  anastomosing  series  of  spaces,  which 
communicate  with  the  open  cavity  of  the  vessel. 

A  careful  search  fails  to  find  a  communication  of  these  spaces 
with  the  capillaries  found  in  abundance  in  the  external  granulation 
tissue.  Above  the  level  of  these  granulations  (Fig.  ii  g.),  and  at 
a  point  abreast  of  the  still  preserved  blood-clot,  which  is  loosely 
attached  at  one  or  two  points  only  to  the  wall,  there  is  a  decided 
thickening  of  the  intima.  On  the  surface  of  this  thickened  layer 
ma)^  be  seen  normal  endothelial  cells,  some  of  which  seem  to  be  in  a 
state  of  division;  just  below  them  is  a  layer  of  spindle-cells,  and 
beneath,  lying  upon  the  elastic  lamina,  are  to  be  found  some  round 
and  irregular  shaped  cells,  with  hyaline  intercellular  substance  and 
an  occasional  vascular  space.  The  tissue  of  this  layer  corresponds 
closely  with  that  seen  in  the  granulations  with  which  it  becomes  con- 
tinuous. Such  an  appearance  as  this  is  usually  explained  by  assum- 
ing a  growth  of  the  cells  of  the  intima.  Little  or  no  change  is  seen 
in  the  endotiielium,  and  the  connective  tissue  growth,  beneath,  is 
directly  continuous  with  the  tissue,  which  has  grown  into  the  vessel 
from  without.  It  is  possible  that  the  layer  of  spindle-cells  may, 
however,  be  a  product  of  the  deeper  layers  of  the  intima.  This  thick- 
ening in  the  intima  is  the  beginning  of  a  growth  of  tissue,  which,  in 
more  advanced  specimens,  is  seen  to  give  the  peculiar  crescent-shape 
to  the  final  cicatrix.  The  remains  of  the  thrombus  are  adherent  to 
the  granulation  tissue,  and  to  the  sides  of  the  vessel. 

Middle  Section. — The  double  ligature  was  applied,  the  blood  hav- 
ing been  excluded,  for  the  purpose  of  determining  whether  a  growth 
of  endothelium  could  be  observed.  This  segment  was  found  col- 
lapsed in  longitudinal  folds.  A  very  slight  amount  of  clot  was  seen 
in  that  portion. 

The  ends  of  the  vessel  have  slightly  opened,  allowing  a  growth  of 
granulation  tissue  to  make  its  way  in  for  a  short  distance  at  either 
end.     A  careful   exploration    fails   to   discover  any  growth  of  endo- 


Experiments  on  Aniuiah.  6i 

thelium.  A  few  large  endothelial  cells  are  scattered  about  in  the 
space,  as  if  desquamated  from  the  inner  wall,  but  no  other  traces  of 
intima  cells  are  seen.  The  granulation  tissue  is  rich  in  capillary 
vessels  which  lie  in  a  mass  of  spindle-shaped  cells,  and,  as  they  can 
be  traced  to  the  edge  of  the  growing  mass,  their  earliest  develop- 
ment can  be  studied.  (Plate  IV,  Fig.  ii-v,  Figs.  12  and  13.)  There 
is  nothing  to  indicate  a  formation  of  vascular  loops  or  a  following 
out  of  an  anastomosing  system  of  cells.  The  vessels  can  be  fol- 
lowed until  the  walls  are  barely  far  enough  apart  to  admit  a  single 
red  corpuscle  (Figs.  12  and  13),  and  are  then  lost  in  the  surrounding 
mass  of  spindle-cells.  The  mode  of  formation  appears  to  consist  in 
the  disposition  of  longitudinal  bands  of  spindle-cells,  developed  from 
round  cells,  offering  a  channel  to  the  blood,  which  has  been  liberated 
from  the  original  vessels  by  a  softening  of  their  walls,  the  blood 
forcing  its  way  into  the  new  soft  tissue  which  then  disposes  itself,  in 
the  shape  of  walls,  around  the  new  spaces  channeled  out.  In  other 
words,  the  new  formation  of  blood-vessels  is  produced  by  an  inter- 
cellar,  rather  than  by  an  intracellular  development.  No  change  is 
noticed  in  the  media  of  this  portion;  the  adventitia  is  infiltrated  by 
the  surrounding  inflammatory  tissue. 

Tlie  Distal  Portion. — The  walls  of  the  vessel  have  slightly  ex- 
panded to  admit  granulations,  to  which  the  thrombus,  a  small  one, 
is  firmly  attached.  The  lower  portion  of  the  thrombus  (that  near- 
est the  lumen)  is  infiltrated,  in  certain  portions,  with  new  cell-growth, 
as  shown  by  the  staining  of  those  portions.  It  has  shrunk  away  from 
the  sides  of  the  vessel,  where  endothelial  cells  may  be  observed  ad- 
hering to  the  edge  of  the  thrombus;  and  also  spindle-cells,  lying  in 
confused  masses,  they  having  been,  apparently,  torn  away  in  the 
shrinking  process,  from  the  walls.  No  vessels  are  to  be  found  enter- 
ing the  thrombus,  either  here  or  in  any  other  portion  of  the  vessel, 
through  the  sides. 

Around  the  three  portions  we  find  a  mass  of  new  tissue,  which 
extends,  upwards  and  downwards  respectively,  upon  the  outer  walls 
of  the  proximal  and  distal  portion,  and  completely  encircles  the 
middle  segment. 

Remarlis. — This  specimen  was  prepared  to  study  the  growth  of 
the  endothelium  when  unobscured  by  blood-clot.  As  no  special 
pains  was  taken  to  preserve  the  attachment  of  the  vessel  to  its 
sheath,  it  may  be  argued  that  no  growth  of  endothelium  was  pos- 
sible, the  blood  supply  from  the  vasa  vasorum  having  been  removed; 
but  the  segment  was  being  rapidly  obliterated  by  the  granulation  tis- 


62  The  Ligature  of  Arte7'ies. 

sue  from  without,  showing  that  it  is  quite  possible  for  such  a  result 
to  be  arrived  at  without  the  aid  of  the  endothelial  cells.  There  is 
no  cell-formation  in  any  of  the  portions  which  might  not  be  referred 
back  to  the  granulation  tissue,  that  is,  to  sources  external  to  the  ves- 
sel; but  it  is  probable  that  some  proliferation  of  the  endothelium  in 
the  proximal  and  distal  portions  had,  nevertheless,  taken  place. 

The  external  and  internal  callus  development  is  well  illustrated 
in  this  specimen;  and  the  mode  by  which  the  central  portion  is  grad- 
ually being  destroyed  is  also  indicated. 

The  formation  of  capillaries  is  conveniently  studied  here  also,  as 
the  surrounding  conditions  have  necessitated  a  growth  in  one  direction 
only.  It  illustrates  also,  very  perfectly,  the  mode  of  "vasculariza- 
tion of  the  thrombus." 

DOUBLE  LIGATURE. 
One  Month. 

Two  ligatures  were  placed  upon  the  femoral  artery  about  one 
inch  apart;  before  removing  the  specimen,  the  limb  was  injected 
with  Prussian  blue.  The  proximal  and  distal  ends  of  the  vessel 
were  united  by  a  long  cord,  in  the  axis  of  which  were  found  the 
remains  of  the  central  portion.  'I'he  proximal  ligature  was  found 
encapsuled,  and  but  slightly  altered.  The  distal  ligature  had  disap- 
peared. 

The  thrombus  of  the  proximal  portion  may  be  divided  into  two 
parts  for  the  purposes  of  description.  The  upper  portion  is  a  typical, 
stratified  clot,  of  an  oval  shape,  and  rests  somewhat  loosely  upon  the 
other  portion,  which  is  rapidly  being  disintegrated  by  granulations. 

The  new  tissue  formed  within  the  walls  of  the  vessel  is  better 
studied  in  specimens  taken  from  the  proximal  portion  (Plate  VI.). 
Here  we  see  that  the  walls  of  the  vessel  have  separated,  and  retracted 
somewhat;  and  a  mass  of  granulation  tissue  has  grown  into  the  inte- 
rior of  the  vessel.  Up  to  a  certain  point,  which  is  readily  recog- 
nized in  the  drawing,  the  tissue  is  precisely  similar  to  that  found 
outside  the  vessels.  It  is  typical  granulation  tissue,  consisting  of 
cells  of  many  shapes,  among  which  the  round,  epithelioid,  and  spindle 
forms  are  seen.  There  are  numerous  small  vessels  which  take  their 
origin  from  the  vessels  of  the  external  growth  (Fig.  i6  g.).  Along 
this  line  of  granulation  tissue,  traces  of  the  thrombus  are  seen,  which 
has  already  been  infiltrated  and  disintegrated  by  a  growth  of  new 
tissue.     At  the  free  surface  of  tiie  lumen,  this  tissue  shows  itself  in 


I 


Experiments  on  Animals.  63 

the  form  of  typical  granulations,  which,  when  studied  with  a  high 
power,  show  the  structure  delineated  in  Fig.  18.  It  consists  of  a 
transparent  more  or  less  homogeneous  ground-work,  in  which  spin- 
dle, round,  or  stellate  cells  are  to  be  found.  The  granulations  are 
exceedingly  tortuous,  and  leave  spaces  in  which  fresh  blood  flows. 
They  are  covered  with  a  single  layer  of  endothelium.  Clumps  of 
pigment  may  be  seen  at  different  points  (d).  The  new  tissue  ex- 
tends farther  up  the  vessel  on  its  sides  than  in  the  centre:  here  we 
find  spindle-shaped  cells  predominating,  which  are  imbedded  in  a 
similar  intercellular  substance;  here  the  endothelium  is  somewhat 
thicker,  and  is  in  strong  contrast  to  the  subjacent  spindle-cell  layer. 
The  growth  extends  much  farther  up  one  side  of  the  vessel  than  the 
other.  The  internal  callus  is  "  eccentric,"  and  this  eccentricity  is 
due  to  the  presence  of  a  collateral  branch  on  the  side  where  the 
growth  is  shorter. 

The  injection  mass  has  forced  its  way  freely  in  between  the 
granulations  on  .the  surface,  and  also  into  the  capillaries  of  the 
granulation  tissue  which  enter  from  below.  We  have,  in  the  interior 
of  the  vessel,  two  independent  channels  for  the  blood  to  run  in,  but 
although  a  successful  injection  has  been  made,  it  fails  to  show  that 
these  two  systems  communicate  with  each  other. 

Central  Poriio?i. — This  part  of  the  vessel  is  evidently  in  a  process 
of  rapid  disintegration.  The  ends  have  shrunk,  and  have  already 
been  acted  upon  by  the  granulation  tissue,  which  penetrates  their 
open  mouths.  Cross  section  shows  the  tube  collapsed,  and  its  walls 
only  slightly  separated  by  fragments  of  clot  and  granulation  cells; 
at  some  points  we  find  these  cells  infiltrating  the  walls  from  without; 
at  others,  from  within.  Near  the  ends  of  the  fragment,  there  is  an 
abundant  growth  of  young  vessels,  accompanying  the  ingrowing 
tissue.  No  growth  from  the  intima,  as  a  layer,  is  seen,  but  clumps 
of  endothelium  are  found  scattered,  here  and  there,  in  the  granula- 
tion tissue. 

Remarks. — This  specimen  illustrates  well  the  condition  of  the 
vessel  one  month  after  ligature;  the  period  when  an  active  ingrowth 
from  the  external  inflammatory  tissue  is  taking  place.  The  walls 
which  have  been  held  in  close  contact  by  the  ligature  have  escaped 
from  its  control  and  have  unfolded,  like  an  opening  flower.  In  the 
specimen  drawn  there  is  no  clot  upon  the  surface,  but  in  the  proxi- 
mal end  such  a  clot  rested  loosely  upon  the  granulations.  The  larger 
vascular  spaces,  frequently  seen  in  tissue  organizing  in  a  thrombus, 
are  here  shown  to  be  spaces  left  between  the  sprouting  granulations, 


64  TJic  Ligature  of  Ai't cries. 

and  are  clearly  distinct  from  the  vessels  of  the  granulation  tissue. 
No  communication  exists  between  them  as  yet.  We  find  in  the  tissue 
extending  up  the  sides  of  the  vessels  the  first  indications  of  a  spin- 
dle-cell structure,  which  is  destined  to  be  a  permanent  feature  of  the 
cicatrix.  The  granulations,  having  grown  into  the  middle  segment, 
are  gradually  disintegrating  and  destroying  its  walls. 

The  experiments  with  the  double  ligature,  of  which  the  fore- 
going are  examples,  show  pretty  conclusively  that  the  endothelium 
is  capable  of  but  slight  formative  power.  In  the  case  of  active  in- 
flammatory changes  there  was  the  least  perceptible  change  in.  this 
layer  of  cells,  and  there  was  no  evidence  to  show  that  cells  in  any 
number  had  wandered  through  the  walls  of  this  portion  of  the  vessel. 
On  the  other  hand,  we  find  its  ends  open  already  at  the  end  of  a 
week,  and  granulation  tissue  penetrating  at  these  points.  At  the 
end  of  the  second  week  the  new  tissue  has  occupied  the  greater  por- 
tion of  this  space,  and  by  the  end  of  the  month  the  lumen  is  filled 
with  granulation  tissue  which  is  now  attacking  the  walls  both  from 
without  and  within.  No  carmine  granules  were  found  within  the 
lumen,  although  the  outer  walls  had  been  invaded  by  masses  of  gran- 
ulation-cells. Immigration  by  wandering  cells,  as  has  been  already 
shown,  undoubtedly  does  take  place,  but  has  no  other  significance 
than  to  serve  as  an  illustration  of  the  fact  that  some  cells  of  the 
invading  mass  of  the  granulation  tissue  may  reach  the  interior  of 
the  vessel  at  an  early  date.  They  are  few  in  number  at  this  period, 
and  exercise  no  essential  function  in  the  process  of  repair  which  is 
going  on.  In  specimens  carefully  prepared  with  antiseptic  precau- 
tions, special  pains  being  taken  to  preserve  the  vascular  supply  of 
nutriment  to  the  endothelium,  this  delicate  cell-layer  was  found  at 
the  end  of  a  week  to  be  in  a  state  of  proliferation.  The  appearance 
of  the  cells  had  changed,  some  of  them  appearing  as  a  mere  globu- 
lar form  of  endothelium,  and  some  as  spindle-shaped  cells,  resem- 
bling those  drawn  in  Fig.  3.  The  presence  of  other  cell-structure 
than  endothelium  could  not,  however,  be  denied  in  these  cases,  for 
a  growth  through  openings  in  the  elastic  lamina,  similar  to  that 
shown  in  Fig.  6,  was  also  seen. 

By  such  a  series  of  experiments  the  fact  of  the  power  of  the  en- 
dothelium to  proliferate  is  proved,  but  it  is  far  from  demonstrated 
that  the  growth  which  obliterates  vessels  or  closes  wounds  in  their 
walls  is  supplied  from  this  source.  The  greater  portion  of  investiga- 
tions bearing  upon  this  question  have  been  conducted  at  too  early  a 


Expcriviciits  oti  Animals.  65 

date  to  show  the  true  relation  of  endotheUum  to  this  process.  The 
later  observations  in  the  present  series  leave  no  doubt  in  the  mind 
as  to  the  way  in  which  the  process  of  obliteration  has  been  accom- 
plished. The  conditions  found  to  exist  in  the  middle  portion  of  double 
ligatured  vessels  differ,  in  no  essential,  from  those  observed  in  the 
proximal  and  distal  portions  of  the  vessel,  so  far  as  the  early  stages 
of  the  process  are  concerned;  and,  if  anything  is  to  be  inferred  from 
the  changes  noted  there,  it  is  not  in  favor  of  the  activity  of  the  en- 
dothelium as  a  prominent  factor  in  the  process  of  repair. 

Femoral.     One  Month. 

A  ligature  was  placed  upon  the  femoral  artery  of  a  dog,  and  the 
animal  was  destroyed  thirty-one  days  after.  The  wound  had  healed 
without  any  inflammatory  disturbance.  Before  removing  the  vessel 
the  external  iliac  was  exposed,  and  the  limb  injected  with  Prussian 
blue.  After  hardening  in  alcohol,  the  specimen  was  divided  longi- 
tudinally, longitudinal  sections  being  made  through  one  half,  and 
transverse  sections  through  the  other.  The  ends  of  the  vessel 
were  separated  from  one  another  about  one  quarter  of  an  inch. 
A  portion  of  the  cotton  ligature  still  remained,  and  was  imbedded 
in  the  centre  of  a  callus  which  bound  together  the  two  portions  of 
the  vessel. 

Proximal  Portion. — There  is  apparently  a  good-sized  thrombus 
distending  the  vessel  in  an  ampulla-like  dilatation;  under  the  micro- 
scope, however,  this  is  found  to  be  completely  permeated  by  granu- 
lation tissue.  The  walls  of  the  vessel  have  separated,  and  have  re- 
tracted slightly  so  that  the  new  tissue  i.s  continuous  with  that  of  the 
external  callus.  Well-formed  granulations  are  found  projecting  from 
the  thrombus  into  the  free  lumen.  Just  above  these  the  calibre  of 
the  vessel  is  narrowed  by  a  growth  from  the  bruised  walls  of  the 
vessel.  In  longitudinal  section,  the  lamina  is  found  to  be  ruptured 
on  both  sides,  from  which  points  this  growth  seems  to  spring  and 
form  in  the  section  a  bridge  across  the  vessel  just  above  the  throm- 
bus. The  tissue  of  which  it  is  formed  grows  down  the  sides  of  the 
vessel  and  becomes  continuous  with  that  sprouting  from  the  throm- 
bus (Fig.  19).  With  high  powers  the  tissue  is  seen  to  consist  of 
spindle-shaped  cells,  and  to  be  directly  continuous  with  the  tissue  of 
the  media,  where  some  cell-proliferation  is  also  going  on.  It  is 
covered  with  a  single  layer  of  endothelial  cells.  At  one  side  there 
is  a  small  plexus  of  vasa  vasorum,  branching  out  from  the  media 
into  this  bridge  of  tissue;  or,  as  it  proved  to  be,  a  diaphragm,  which 
5 


66  TJic  Ligature  of  Arteries. 

greatly  narrows  the  calibre  of  the  vessel.  One  or  two  similar  ruptures 
in  the  lamina  are  noticed  lower  down,  whence  new  tissue  is  seen 
growing  into  the  thrombus.  The  cells  found  in  the  granulation  tis- 
sue are  round  and  spindle-shaped,  the  latter  being  quite  numerous, 
and  arranged  in  fasciculi. 

Distal  Portion. — No  thrombus  is  seen  here,  but  the  conditions  are 
otherwise  very  much  the  same.  The  granulations,  which  could  be 
better  studied  here,  sprout  in  an  irregular  manner,  leaving  spaces 
communicating  with  the  lumen  of  the  vessel  (Fig.  17),  which  are  lined 
with  a  delicate  endothelium. 

The  injection  mass  has  run  well  between  the  granulations,  and 
penetrates  some  distance  down  mto  the  tissue,  both  at  the  proximal 
and  distal  ends.  There  is  also  a  rich  injection  of  the  vasa  vasorum, 
and  the  vessels  of  the  external  callus;  the  mass  has  run  particularly 
well  into  a  plexus  of  vessels  which  surrounds  the  end  of  the  distal 
portion.  These  vessels  do  not  appear  to  communicate  with  the 
lumen  of  the  vessel,  except  at  one  point,  shown  in  Fig.  19.  There 
is,  therefore,  u  flow  of  blood  into  the  new  tissue  from  two  directions; 
first,  from  the  lumen  between  the  sprouting  granulations;  and, 
secondly  from  the  vasa  vasorum  and  small  vessels  ramifying  in  the 
callus.  The  latter  project  some  distance  into  the  internal  callus, 
but  cannot  be  followed  to  a  point  where  they  could  receive  the  mass 
penetrating  from  the  interior.  This  latter  mass  indicates  a  free 
anastomosis  of  the  spaces  between  the  granulations.      (Fig.  17.) 

Remarks. — This  specimen  illustrates  the  second  stage  of  repair 
at  its  height:  the  opening  of  the  vessel  and  the  ingrowth  of  granula- 
tions. Vascular  communication  is  not  yet  established  between  the 
vessels  of  the  granulation  tissue  and  the  lumen. 

An  examination  of  the  proximal  and  distal  ends  of  the  specimens, 
ranging  from  two  weeks  to  one  month,  shows  the  development  of  what 
may  be  called  the  second  period  in  the  process  of  repair;  that  which 
follows  the  separation  of  the  vessel  from  the  ligature,  and  the  expan- 
sion of  its  ends.  At  the  end  of  two  weeks  we  find,  in  one  specimen, 
that  the  walls  of  the  vessel  have  separated  from  one  another,  and  that 
granulation-like  masses  of  tissue  are  growing  into  the  lumen,  partly 
pushing  to  one  side  the  thrombus,  and  partly  infiltrating  it.  Between 
these  granulations  are  spaces  which,  lined  with  endothelium  at  a  lat- 
ter period,  are  filled  with  fresh  blood,  and,  in  injected  specimens, 
with  injection  mass,  A  careful  search  fails  to  establish  the  fact  that 
these  spaces  communicate  with  the  capillary  vessels  which  accom- 


Experiments  on  Animals.  6y 

pany  the  granulations.  By  means  of  these  channels,  the  blood  in 
the  lumen  of  the  vessel  is  able  to  penetrate  some  distance  into  the 
organizing  cicatrix.  The  development  of  the  cicatrix  at  this  period, 
although  it  varies  greatly  according  to  the  amount  of  thrombus  pres- 
ent, cannot  be  said  to  have  passed  the  granulation-stage.  No  great 
amount  of  differentiation  of  cell-elements  has  yet  taken  place;  but 
one  begins  to  observe  an  accumulation  of  masses  of  spindle-shaped 
cells  at  certain  points. 

A  careful  examination  of  all  specimens  within  the  limits  of  this 
period  fails  to  demonstrate  any  growth  which  can  have  been  devel- 
oped from  the  endothelial  layer  only.  It  is  true  that  we  find  a  thick- 
ening on  the  inner  walls  of  the  vessel,  extending  for  some  distance 
up  above  the  point  of  ligature,  and  that,  in  earlier  stages,  a  prolife- 
ration of  the  cells  of  the  endothelium  has  been  satisfactorily  demon- 
strated; but  there  is  no  evidence  to  show  that  this  layer  plays  such 
an  important  role  in  the  process  of  cicatrization  as  has  usually  been 
ascribed  to  it. 

In  none  of  the  numerous  experiments  made  was  an  isolated  mass 
of  growing  endothelium  demonstrated.  All  growths  on  the  interior 
wall  of  the  vessel  were  continuous  with  granulation  tissue,  or  with 
other  layers  of  the  vessel-wall,  from  which  cell-growth  was  seen  to 
develop.  The  ruptures  of  the  lamina  elastica  in  the  neighbor- 
hood were  numerous,  even  when  great  care  had  been  taken  to  avoid 
injury  in  the  application  of  the  ligature.  The  lamina  is,  moreover, 
not  a  continuous  membrane,  but  is  perforated  with  spaces,  leaving  a 
free  communication  with  the  tissues  of  the  media.  All  barriers  are, 
however,  at  this  period  broken  down,  and  a  superabundance  of  tis- 
sue is  provided  from  without,  from  which  the  new  tissue,  ascribed 
by  authors  to  a  growth  from  the  intima,  could  easily  have  sprung. 
The  thrombus,  or  such  portion  of  it,  as  has  not  already  been  disin- 
tegrated and  absorbed,  is  found  resting  upon  the  granulations  grow- 
ing up  beneath  it,  and  lifted  farther  into  the  lumen  by  them. 

Femoral.     Three  Months. 

The  femoral  of  a  large  Newfoundland  dog  was  tied  with  a  small 
cotton  thread.  The  wound  healed  by  first  intention,  and  the  animal 
was  destroyed  at  the  end  of  three  months.  Before  removal,  the 
femoral  was  injected  with  Berlin  blue.  The  specimen  was  then 
placed  in  alcohol,  and  subsequently  divided  into  halves  by  a  longi- 
tudinal section.  The  ends  of  the  artery  had  retracted  about  an 
inch,  and   were   untied  by  a  band  of  connective  tissue  fibres;  all 


68  The  Ligature  of  Arteries. 

trace  of  thrombi  had  disappeared;  the  ends  of  the  vessel  formed 
each  a  cul-de-sac,  the  ends  of  which  appeared,  to  the  naked  eye,  to 
be  closed  by  a  cicatrix  considerably  thicker  than  the  vessel-walls, 
and  showing  traces  of  the  injection  mass.  One  half  of  the  proxi- 
mal end  was  cut  into  transverse  sections,  and  longitudinal  sections 
were  made  of  the  other  portions. 

Proximal  End. — (Plate  VIII.,  Fig.  20). — Here  the  walls  of  the 
vessel  are  slightly  separated  from  one  another,  and  the  intervening 
space  is  filled  with  a  cicatrix,  which  also  occupies  a  portion  of  the 
lumen,  rounding  it  off,  very  much  like  the  interior  of  the  small  end 
of  an  e.gg.  The  surface  is  lined  with  a  la5'er  of  endothelium  of  nor- 
mal thickness.  Beneath  this,  growing  up  on  each  side,  and  encir- 
cling the  fundus  also,  is  a  layer  of  delicate  spindle-cells  running  paral- 
lel to  one  another,  and  parallel  to  the  arc  of  the  circle  formed  by  the 
cicatrix.  Under  high  power,  and  examined  both  in  cross  and  longi- 
tudinal sections,  these  are  seen  to  resemble,  closely,  muscular  cells. 
The  staff-shaped  nuclei  are  characteristically  shown.  They  come 
out  more  clearly  and  well  defined  when  stained  with  an  aniline  dye 
mounted  in  Canada  balsam,  and  examined  with  a  Zeiss  oil-immer- 
sion (Fig.  22).  Prepared  in  glycerine,  they  appear  as  in  Fig.  21. 
The  cells  are  surrounded  by  a  hyaline,  and,  at  times,  a  slightly 
fibrillated  intercellular  substance.  This  band  of  muscular  fibre  forms 
a  crescent-shaped  layer,  slightly  thicker  in  the  middle,  with  tapering 
horns,  which  present  upwards,  and  line  the  sides  of  the  vessel  for 
the  distance  of  about  one  quarter  of  an  inch  from  its  extremity;  one 
side  being  longer  than  the  other.  This  crescent  can  be  separated 
entire  with  needles;  it  is  found,  however,  to  be  firmly  attached  to 
the  connective  tissue  portions  of  the  cicatrix  below  it,  and  to  the 
media  at  points  where  the  elastic  lamina  has  been  ruptured.  Bun- 
dles of  these  fibres  are  deflected,  and  surround  the  walls  of  the  larger 
vessel,  running  through  the  cicatrix.  (Fig.  20,  f.)  Beneath  this 
muscular  laj^er,  and  filling  out  the  space  remaining  between  the 
slightly  separated  walls  of  the  vessel,  is  a  mass  of  connective  tissue 
fibres  such  as  are  usually  seen  in  cicatricial  tissue.  The  fibres 
are  wavy,  swollen,  and  transparent,  running  in  various  directions, 
and  continuous  with  fibres  of  the  ligamentous  band  outside  the 
vessel. 

The  cicatrix  is  pierced  in  the  centre  by  a  large  arteriole  (v)  which 
rapidly  narrows  its  calibre,  and  becomes  continuous  with  the  numer- 
ous capillary  vessels  in  the  new  tissue:  these  anastomose  with  an- 
other rich  capillary  net-work  ramifying  in  the  ligament  at  its  point 


Experiments  on  Animals.  69 

of  union  with  the  vessel,  and  ending  in  two  or  three  small  vessels 
which  extend   lengthwise  through  it. 

Cross  sections  of  the  other  half  of  this  portion,  made  specially 
with  reference  to  the  muscular  layer,  confirm  their  spindle-shape, 
setting  at  rest  any  doubts  as  to  there  being  a  layer  of  flat  endothelial 
cells.  Cross  sections,  including  the  portion  of  the  cicatrix  entirely 
filling  the  lumen,  again  show  some  of  these  cells  in  profile,  and  if 
these  be  examined  close  to  the  edges  of  the  bruised  media,  it  can  be 
shown  that  an  outgrowth  of  the  muscular  cells  of  this  coat  has  taken 
place  into  the  cicatrix.  The  adjacent  cells  of  the  media  are  also 
shown  in  the  drawing,  with  the  intervening  elastic  fibres.  (Fig.  23.) 
Some  of  these  sections  include  a  point  where  a  branch  has  been  given 
off  some  distance  from  the  end  of  the  stump.  Here  the  cicatricial 
tissue  (one  of  the  horns  of  the  crescent)  is  disposed  on  the  opposite 
side  of  the  vessel.  It  is  thickest  there,  and  as  it  approaches  the 
branch,  tapers  away  rapidly  and  disappears  at  the  boundary  line. 
The  adventitia  as  it  approaches  the  end  of  the  vessel  is  somewhat 
broken,  and  terminates  abruptly  at  about  the  same  point  as  the  media. 
The  lamina  elastica  is  well  preserved,  but  broken  at  one  or  two 
points. 

Distal  End. — About  the  same  conditions  exist  here  as  in  the 
proximal  end.  The  layers  of  the  new  tissue  are  not  so  thick. 
The  muscular  layer  extends  about  as  far  up  the  wall  as  in  the  proxi- 
mal. The  larger  vessel,  penetrating  the  cicatrix,  is  at  one  corner, 
and  anastomoses  with  a  cluster  of  capillaries  in  the  fibrous  band  out- 
side. In  all  these  vessels  the  injection  mass  is  distinctly  seen,  and  it 
appears  to  be  supplied  from  the  femoral  artery  directly  and  not  through 
the  vasa  vasorum. 

Remarks. — This  specimen  offers  a  type  of  the  permanent  cicatrix. 
In  shape  it  is  a  crescent,  the  longer  horn  of  which  runs  up  on  the  side 
opposite  to  which  a  branch  is  given  off,  showing  the  influence  of  a 
branch  upon  the  ultimate  shape  of  the  cicatrix.  (Thoma,  Schultz.) 
The  presence  of  a  muscular  layer  is  here  clearly  established:  its 
presence  within  the  vessel,  in  what  might  be  regarded  as  a  continu- 
ation or  thickening  of  the  intima,  might  give  rise  to  doubt  as  to  the 
muscular  nature  of  these  cells.  They  are,  however,  found  in  the 
normal  intima  of  arteries  occasionally,  as  well  as  in  veins,  and  as 
we  have  seen,  a  special  formation  of  muscular  tissue  occurs  at  points 
where  extra  support  is  needed,  as  at  the  bifurcation  of  the  aorta 
(Thoma).  It  seems  highly  probable,  therefore,  that  we  have  here 
a  cup-shaped  muscle,  a  sort  of  levator  muscle,  whose  function  is  to 
withstand  the  pressure  of  the  blood-column. 


70  TJic  Ligature  of  Arteries. 

TEMPORARY  LIGATURE. 
Three  Months. 

A  ligature  was  placed  around  the  carotid  of  a  large  dog,  tied  in 
a  slip-knot  with  sufificient  strength  to  rupture  the  inner  walls  of 
the  vessel,  and  then  removed.  On  feeling  the  artery  with  the 
thumb  and  finger,  a  slight  circular  indentation  could  be  noticed 
on  the  inner  walls,  although  no  alteration  was  perceptible  in  the 
outer  wall.  On  dissecting  out  the  vessel  a  circular  indentation  was 
seen,  with  a  slight  ridge  above  and  below  it.  It  was  placed  in  alcohol 
and  subsequently  divided  longitudinally  into  halves.  Both  transverse 
and  longitudinal  sections  were  made  for  microscopic  study. 

In  longitudinal  section,  two  V  shaped  cuts  were  found,  a  short 
distance  from  one  another,  extending  through  the  media,  marking 
the  site  of  the  ruptures  made  by  the  ligature,  which  in  this  case, 
was  adjusted  twice. 

The  cuts  are  partially  filled  by  cicatricial  tissue  (Fig.  25),  com- 
posed of  cells  similar  to  those  found  in  the  media,  and,  like  them, 
running  in  circular  bands  round  the  vessel.  In  cross  sections  of 
the  vessel  they  appear  as  spindle-shaped  cells  with  long  nuclei.  A 
few  spindle-cells  can  be  seen  in  the  drawing,  although  the  power  is 
not  high  enough  to  show  them  well.  The  new  tissue  is  intimately 
connected  with  the  media,  and  is  tolerably  distinct  from  the  other 
layers.  A  thin  covering  of  endothelium  runs  over  this  tissue,  and  is 
continuous  with  the  endothelial  lining  of  the  vessel,  both  above  and 
below. 

Re?narks. — This  experiment  shows  that  the  new  tissue,  formed  to 
repair  the  injury  done  by  a  temporary  ligature,  in  all  respects  resem- 
bles that  of  the  media,  and  is  probably  a  growth  of  muscular  cells.  In 
Zahn's  experiments  the  specimens  were  examined  too  early  to  demon- 
strate the  permanent  cicatricial  tissue. 

In  a  second  experiment  of  this  kind  a  temporary  ligature  was 
placed  upon  the  carotid,  and  immediately  removed,  the  animal  being 
destroyed  at  the  end  of  one  week.  The  same  kind  of  V  shaped  rent 
was  observed,  extending  through  the  media  to  the  adventitia.  In 
this  case,  a  thin  layer  of  fiat  endothelial  cells  had  grown  down  into 
the  rent  on  either  side,  but  nowhere  formed  a  thickened  layer.  The 
cells  of  the  media  are  in  a  state  of  proliferation  for  some  little  dis- 
tance from  the  surface  of  the  wound.  There  are  some  granulation 
cells  in  the  adjacent  portion  of  the  adventitia.  The  granulation 
tissue  just  beneath  the  endothelium  is  evidently  formed  by  a  growth 


Experiments  on  Animals.  yi 

from  the  media,  and  from  cells  wandering  in  from  the  peri-adventitia, 
the  surface  of  the  wound  being  already,  in  great  part,  covered  by  an 
extremely  thin  layer  of  endothelium.  There  could  be  no  better  proof 
of  the  activity  of  the  media,  and  of  the  subordinate  part  played  by 
the  intima  than  that  afforded  by  these  two  specimens. 

Carotid.     Four  Months. 

This  specimen  was  prepared  to  show  the  completed  cicatrization, 
but,  on  removal  it  was  found  that  the  process  was  not  fully  accom- 
plished at  the  proximal  portion.  The  two  ends  of  the  vessel 
were  united  by  a  cord-like  mass,  and  it  was  evident  that  the  vessel 
was  slowly  becoming  obliterated  up  to  the  first  collateral  branch. 
Owing  to  the  length  of  the  main  trunk  of  this  vessel,  which  gives  off 
no  branch  of  size  for  a  considerable  space,  a  much  longer  time  was 
evidently  necessary  for  a  completion  of  the  process  of  repair,  than 
when  the  ligature  is  applied  nearer  a  large  branch. 

Pro.xivial  Portio7i.—Yxovi\  the  point  of  ligature,  for  a  considerable 
distance,  the  vessel  appears  to  retain  its  form  and  to  be  filled  with  a 
growth  of  cicatricial  tissue,  but,  on  examination  of  longitudinal  sec- 
tions, it  is  found  that  the  walls  of  the  vessel  have  disappeared  and 
are  replaced  by  a  ligamentous  band  of  connective  tissue.  On  near- 
ing  the  lumen,  traces  of  the  media  are  found,  and,  a  little  higher  still, 
the  media  is  seen  unaltered,  its  inner  margin  being  sharply  defined 
by  the  lamina.  Here  it  encloses  a  connective  tissue,  with  longitu- 
dinal fibres,  capillary  vessels  and  numerous  round  and  spindle-shaped 
cells.  The  thrombus  rests  upon  this  tissue  and  is  still  in  part  pre- 
served, slightly  distending  the  calibre  of  the  vessel.  It  does  not 
appear  to  be  infiltrated  with  new  tissue,  but  is  encapsuled  by  it, 
granulations  closing  in  about  it,  and  separating  it  from  the  lumen. 
There  is  a  thickening  of  the  intima,  covered  with  a  new  growth  of 
endothelium  extending  from  this  point  for  some  distance  equally  on 
all  sides  of  the  vessel,  and  gradually  tapering  off  to  a  normal  thick- 
ness. It  seems  as  if  the  clot  were  of  comparatively  recent  origin, 
and  were  assisting  in  the  further  obliteration  of  the  vessel. 

Distal  Efid.—^ere  the  cicatrization  is  complete,  a  point  having 
been  reached  where  a  branch  is  given  off  (Fig.  26).  There  is  no 
thrombus.  The  vessel  is  converted  into  a  cord-like  mass  near  the 
point  of  ligature,  and,  nearer  the  point  shown  in  the  drawing,  is  filled, 
as  in  the  other  portion,  with  connective  tissue.  That  part  border- 
ing upon  the  lumen,  however,  consists  of  a  tissue  abounding  in  cells 
quite  different  in  character  from  those  above  mentioned.     Here  we 


72  The  Ligature  of  Arteries. 

find  a  tissue,  consisting  of  longitudinal  rows  of  spindle-shaped  cells 
with  staff-shaped  nuclei  which  form  a  cul-de-sac  from  the  apex  of 
which  a  vessel  projects  into  the  new  tissue,  and  breaks  up  into  a  capil- 
lary net-work.  The  shape  of  the  cicatrix,  as  determined  by  the 
branch,  is  characteristic.  It  does  not  extend  symmetrically  up  the 
sides  of  the  vessel,  but  is  thicker  and  longer  on  the  side  opposite  to 
the  branch.  It  is  interesting  to  note  that,  on  the  side  on  which 
the  branch  is  given  off,  the  cicatrix  extends  beyond  thg  point  of 
origin  of  the  branch,  instead  of  terminating  at  that  point,  as  has 
been  represented  by  observers.  (Schultz.)  With  high  powers,  the 
staff-shaped  nuclei  are  well  shown  (Fig.  28),  and  it  will  be  observed 
that  at  some  points  shown  in  the  drawing  there  are  breaks  in  the  con- 
tinuity of  the  lamina  through  which  similar  cells  are  growing  from 
the  media.  Cross  sections  of  the  vessel  at  this  point  show  that  these 
cells  are  not  flattened  endothelium,,  but  are  genuine  spindle  cells 
(Fig.  24).  The  inner  surface  of  the  cicatrix  is  lined  with  a  single 
layer  of  endothelium. 

Remarks. — This  specimen  illustrates  the  manner  in  which  a  long 
trunk  is  converted  into  a  cord.  The  process  is  still  going  on  in  the 
proximal  end;  the  walls  of  the  vessel  gradually  disappearing  as  anew 
growth  penetrates  deeper  into  its  interior.  There  is  great  contrac- 
tion of  the  vessel,  which  is  much  reduced  in  size.  The  peculiar 
shape  of  the  completed  cicatrix,  at  the  distal  end,  is  evidently  in- 
tended to  adapt  the  size  of  the  tube  to  the  diminished  blood-supply 
which  now  flows  down  to  be  diverted  into  a  collateral  branch,  or 
to  find  its  way  into  a  small  terminal  arteriole.  Long  branchless  trunks, 
like  this,  require  a  much  greater  amount  of  time  to  complete  the  pro- 
cess of  repair  than  vessels  having  numerous  branches,  although  they 
may  be  equal  in  size.  The  growth  of  muscular  cells  into  the  new 
cicatricial  tissue,  through  the  intervals  in  the  elastica,  is  a  reminder 
of  what  has  been  observed  l)y  Thoma  in  the  intima  of  the  carotid 
and  aorta  of  man,  and  in  the  obliterating  tissue  of  the  umbilical 
artery. 

These  specimens  show  that  at  least  three  months  are  required  to 
complete  the  process  of  repair  in  the  large  arteries  of  dogs.  The 
period  is,  however,  a  variable  one,  and  appears  to  depend  upon  the 
proximity  of  a  large  branch  rather  than  upon  the  size  of  the  vessel. 
In  the  carotid  artery,  the  process  of  obliteration  is  not  yet  complete 
at  one  end,  but,  at  the  other,  the  presence  of  a  branch  of  considera- 
ble size  necessitates  ablood-supply  which  renders  further  obliteration 


Experiments  on  Animals.  73 

in  this  direction  unnecessary.  More  time  would  liave  been  required 
to  have  closed  the  calibre  at  the  other  end,  where  no  branch  was 
found  for  a  considerable  distance  from  the  point  of  ligature. 

The  temporary  formations,  which  were  so  characteristic  of  the 
previous  specimens,  have  now  disappeared,  and  we  find  the  two  ends 
of  the  vessel,  in  the  case  of  the  femoral  artery,  united  by  a  slender 
cord.  The  cord  holding  the  ends  of  the  carotid  artery,  on  the 
other  hand,  is  still  of  a  thickness  corresponding  to  the  size  of  the 
vessel.  The  internal  cicatrix  has  also  become  more  compact,  and  in 
the  femoral  artery,  occupies  an  inconsiderable  portion  of  the  lumen  of 
the  arterial  stump.  In  the  carotid  artery,  however,  that  portion  which 
has  become  permanently  cicatrized  contains  a  much  longer  internal 
cicatrix.  The  size  of  the  permanent  cicatricial  tissue  appears,  there- 
fore, to  var)'-,  occupying  a  greater  portion  of  the  interior  of  the 
vessel  in  larger  vessels.  'I'he  cord  which  unites  the  end  of  the 
femoral  consists  of  connective  tissue:  we  see  no  traces  of  the  vessel 
walls  in  it.  Under  the  microscope  it  is  seen  to  be  continuous  with 
the  adventitial  and  periadventitial  tissue.  The  vessels  of  the  inter- 
nal cicatrix  ramify  in  it.  It  appears  to  represent  the  cicatricial 
remainder  of  the  external  callus,  which  has  now  entirely  disappeared, 
and  has  evidently  been  considerably  elongated  by  a  retraction  of  the 
two  ends  of  the  vessel. 

A  microscopical  study  of  the  internal  cicatrix  brings  out  the  chief 
point  of  interest  m  these  specimens.  In  the  femoral  artery,  at  its 
distal  end,  there  is  a  cup-shaped  mass  of  cicatricial  tissue.  When 
observed  with  a  moderately  high  power,  it  is  seen  to  extend  higher 
on  one  side  of  the  vessel  than  the  other,  and  to  be  asymmetrical. 
It  is  pierced  at  the  most  dependent  portion  of  the  lumen  by  an  arte- 
riole, which  rapidly  breaks  up  into  smaller  vesesls  which  lose  them- 
selves in  the  cord  outside.  The  centre  of  this  cicatrix  is  made  up  of 
ordinary  connective  tissue,  but  this  is  covered  by  a  layer  nearer  the 
interior  of  the  vessel,  which  at  once  attracts  the  attention  of  the 
observer,  consisting  as  it  does  of  elongated,  spindle-shaped  cells 
running  parallel  with  one  another.  A  thick  layer  is  thus  formed  be- 
neath the  new  endothelium,  and  is  prolonged  upward  on  the  sides  of 
the  vessel  in  the  manner  already  described.  These  cells  are  closely 
placed  together,  and  arranged  with  great  regularity  parallel  to  the 
surface  of  the  lumen.  When  studied  with  such  re-agents  as  serve 
best  to  display  their  nuclei,  these  are  found  to  be  greatly  elongated. 
In  cross  sections  the  contour  of  the  cells  is  circular.  In  short,  the 
general  appearance  resembles  closely  the  muscular  cells.     Their  dis- 


74  TJic  Ligature  of  Arteries. 

position  in  the  cicatricial  tissue,  and  the  sharp  contrast  which  they 
afford  to  the  connective  tissue  portion  of  the  cicatrix,  also  favor  this 
view;  as  does  also  their  arrangement  round  the  walls  of  the  arteriole 
which  penetrates  the  cicatrix.  A  careful  comparative  study  of  these 
cells  with  those  found  in  the  media  of  the  same  specimen  fails  to 
bring  out  any  essential  points  of  difference;  their  size,  shape,  and 
general  bearing  towards  reagents  being  the  same. 

The  drawings  taken  from  the  four  months'  specimen  of  these 
cells  shows  not  only  the  arrangement  of  the  nuclei,  but  also  their 
direct  origin  from  cells  in  the  media.  (Fig.  28.)  Such  slight  solu- 
tions of  continuity  as  are  frequently  seen  in  vessels  are  probably 
normal:  there  are,  however,  always  a  number  of  such  openings,  some 
of  considerable  size  near  the  point  of  ligature,  due  to  injury  re- 
ceived. In  the  early  stages  of  repair,  a  growth  of  cells  may  be 
frequently  observed  penetrating  the  thrombus  through  one  of  these 
clefts.  (Fig.  6.)  Later,  fully  developed  muscular  cells  are  found  in 
these  clefts.  In  the  specimen  of  three  months,  where  the  walls  were 
ruptured  internally  by  a  ligature  which  was  immediately  removed, 
the  growth  resembles  closely  newly  formed  muscular  tissue.  The  cells 
here  are  arranged  circularly,  and  not  longitudinally,  as  in  the  other 
specimens.  The  shape  of  the  cicatrix  in  the  permanently  ligatured 
vessel,  deserves  notice.  The  asymmetry  of  the  cicatrix  in  the 
femoral  artery  is  due  to  the  presence  of  a  branch  of  considerable 
size;  the  long  horn  of  the  new  tissue  running  up  the  side  of  the 
vessel  opposite  to  that  from  which  the  branch  is  given  off.  In  the 
four  months'  specimen  this  peculiarity  is  more  strongly  marked. 
There  is  a  large  branch  near  the  distal  end,  the  cicatrix  forming  quite 
a  thick  layer  opposite  that  vessel.  It  is  interesting  to  note  that  the 
cicatrix  also  continues  beyond  the  point  of  origin  of  the  vessel  on 
the  other  side.  (Fig.  26.)  The  design  of  this  particular  arrange- 
ment is  apparent.  The  vessel  has  contracted  at  this  point  and  above 
much  within  its  former  calibre;  but  this  has  not  been  sufficient  in 
degree  at  certain  points  to  adapt  the  lumen  to  the  greatly  diminished 
blood  current,  which  now  has  an  outlet  through  the  collateral  branch 
and  terminal  arteriole  only.  The  shape  of  the  cicatricial  tissue 
accurately  complements  the  contraction  of  the  walls  by  effecting  an 
adaptation  to  the  size  of  the  blood-stream.  This  point  was  first  noted 
by  Schultz,  and  its  analogy  with  the  narrowing  of  that  portion  of  the 
arterial  blood-vessels  specially  concerned  in  the  placental  circulation 
has  been  traced  by  Thoma.  But  Schultz  failed  to  note  its  continua- 
tion on  the  side  of  the  branch  above  its  point  of  origin.     In  excep- 


Experiiiiciits  on  Animals.  75 

tional  cases,  where  a  trunk  exists  with  no  branches  except  at  long 
intervals,  the  process  of  repair  may  be  considerably  delayed,  owing 
to  the  time  requisite  for  a  gradual  obliteration  of  a  considerable  por- 
tion of  the  arterial  calibre.  In  such  a  case  as  this,  it  is  probable  that 
portions  of  the  vessel-wall  are  gradually  disintegrated  and  absorbed 
during  the  reparative  process,  in  a  manner  similar  to  that  which 
occurs  in  the  middle  portions  of  a  double  ligatured  vessel. 

The  nature  of  the  cicatricial  tissue  is  complex.  The  inner  surface 
is  lined  with  an  endothelial  layer  in  no  way  differing  from  that 
seen  in  other  portions  of  the  vessel.  Beneath  this  is  a  layer  consist- 
ing largely  of  muscular  cells,  arranged  longitudinally,  and  giving  firm 
support  to  the  walls  of  the  end  of  the  arterial  stump.  Outside  of 
this  is  a  layer  of  connective  tissue.  We  thus  have  three  layers,  or 
coats,  to  the  newly  formed  wall  closely  resembling  those  of  the  nor- 
mal arterial  wall.  The  well-marked  type  of  the  muscular  portion  of 
the  cicatrix  may,  in  part,  be  due  to  the  fact  that  muscular  tissue  is 
unusually  abundant  in  the  arteries  of  dogs. 

THE    HORSE. 

The  following  series  of  experiments  was  performed  to  show  the 
coarse  appearances  of  the  process  of  repair  in  arteries.  In  each  case 
the  carotid  artery  was  tied,  because  it  is  the  most  convenient  of  the 
large  arteries  upon  which  to  operate  in  the  horse.  No  special  pains 
were  taken  to  preserve  antisepsis,  and  some  of  the  specimens  were 
ruined,  owing  to  the  degree  of  suppuration.  In  those  selected,  the 
amount  of  inflammation  was,  however,  not  excessive;  and  the  results 
obtained  were  such  as  served  to  show  prominently  the  usual  changes 
which  the  ends  of  the  vessel  undergo  during  the  process  of  repair. 
A  specimen  which  would  show  the  final  cicatrix  at  its  ultimate  stage 
of  development  was  not  obtained,  but  the  investigations  were  carried 
sufficiently  far  to  illustrate  the  growth  of  the  callus,  its  subsequent 
absorption,  and  the  various  alterations  which  take  place  in  the 
arterial  walls,  as  well  as  those  observed  in  the  interior  of  the  vessel. 

Owing  to  the  great  size  of  the  vessels,  this  series  is  particularly 
well  adapted  to  demonstrate  to  the  naked  eye  the  somewhat  com- 
plicated nature  of  the  process,  which  is  shown  to  advantage  by  mak- 
ing longitudinal  sections,  and  dividing  the  specimen  into  equal  halves, 
thus  preserving  all  reparative  changes  in  their  proper  relations  to 
one  another.  The  usual  custom  of  dissecting  away  all  external  in- 
flammatory tissue,  thus  laying  bare  the  ligature,  has  been  carefully 
avoided. 


76  TJie  Ligatm'c  of  Arteries. 

Two  Weeks. 

The  vessel  is  imbedded  at  the  point  of  ligature  in  a  callus 
about  three  quarters  of  an  inch  in  diameter,  and  about  two  inches 
in  length.  The  silk  ligature  appears  to  be  uninjured.  The  wound 
had  healed  by  first  intention,  and  the  ligature  is  completely  im- 
bedded in  the  callus.  On  either  side  of  the  ligature  the  ends  of 
the  vessel,  which  are  still  in  close  contact  with  it,  appear  to  be  dis- 
tended by  the  thrombi,  particularly  the  proximal  end  which  has  the 
usual  ampulla-like  dilatation.  There  is,  in  reality,  no  dilatation, 
but  the  vessel,  above  and  below  the  thrombi,  has  greatly  contracted. 
The  proximal  thrombus  is  shorter,  owing  to  the  presence  of  a  branch 
near  by.  Why  it  should  be  so  much  lighter  in  color  than  the  distal 
thrombus  which  is  dark  and  stratified,  does  not  appear.  They  both 
seem  to  be  intimately  connected  with  the  walls  of  the  vessels  at  their 
bases  only.  The  walls  have  not  yet  opened,  the  media  forming  a 
continuous  line  above  and  below  the  ligature.  To  the  uninitiated 
observer  it  would  appear  that  the  healing  process  is  complete.  There 
is  evidently  no  appreciable  thickening  of  the  intima,  certainly  not 
enough  to  form  a  thickened  layer,  although  possibly,  a  cell  growth 
sufficient  to  hold  the  base  of  the  thrombus  firmly  in  position,  may 
exist.  The  adventitia  may  be  traced  down  the  sides  of  the  vessel 
into  the  callus  (Fig.  i.  Frontispiece),  but  apparently  it  has  been 
absorbed  at  the  point  of  ligature. 

Remarks. — The  first  stage  of  the  healing  process,  namely,  the 
absorption  of  the  outer  walls  of  the  vessel  by  the  granulation  tissues 
of  the  callus,  so  that  they  may  retract  and  expand,  admitting  a  growth 
of  granulation  tissue,  has  not  yet  been  completed. 

One  Month, 

A  silk  ligature  was  placed  on  the  carotid  of  a  mare,  and  the 
animal  was  destroyed  one  month  later.  The  wound  healed  with- 
out special  irritation,  a  small  sinus  still  discharging  slightly  at 
the  time  of  death.  The  artery,  on  being  removed,  was  found  en- 
closed in  a  very  extensive  callus,  a  spindle-shaped  mass  about  five 
inches  in  length  and  one  and  three  quarters  inches  in  thickness. 
The  specimen  was  accidentally  cut  open  just  above  the  ligature,  and 
some  puriform  material  oozed  out.  After  hardening  the  specimen 
and  laying  it  open  longitudinally  this  fluid  was  found  to  come  from 
a  portion  of  softened  thrombus.     In  the  centre  of  the  callus  is  a  cav- 


Expcriinoits  on  Animals.  yy 

ity,  the  size  of  a  pea,  partly  filled  with  granular  debris^  indicating 
the  site  of  the  ligature;  it  communicates  by  a  fistulous  opening  with 
the  surface.  Above  and  below,  and  slightly  retracted  from  the  liga- 
ture, the  walls  of  the  vessel  can  be  seen  completely  imbedded  in  the 
inflammatory  tissue  surrounding  it,  and  filling  its  lumen,  which  is 
obliterated,  for  the  space  of  an  inch  and  a  half  on  either  side  of  the 
ligature.  Beyond  this  internal  growth  lies  the  thrombus,  about  an 
inch  in  length.  In  the  proximal  portion  there  is  a  mass  of  softened 
thrombus  at  the  junction  of  the  clot  with  the  internal  growth  and 
this  softened  mass  communicates  by  a  narrow  fistulous  track  with 
the  ligature.  There  are  two  such  softened  spots  in  the  distal  portion, 
one  lying  in  the  middle  of  the  internal  callus,  and  both  communicat- 
ing with  the  ligature,  as  on  the  other  side.  As  the  artery  enters  the 
callus,  there  is  a  noticeable  thickening  of  the  media  easily  seen  with 
the  naked  eye.  As  the  point  of  ligature  is  approached,  the  outline 
of  the  wall  becomes  less  distinct,  and  the  media  can  no  longer  be 
traced.  This-  thickening  of  the  media  is  found  to  be  due  to  a  prolif- 
eration of  the  muscular  cells  of  that  layer.  At  its  widest  part,  where 
the  coat  is  treble  its  natural  thickness,  there  is  a  marked  increase  in 
the  number  of  cells.  In  some  places  several  small  cells  occupy  the 
space  of  a  muscular  cell.  The  muscular  cells,  which  are  usually 
matted  together  in  bundles,  are  now  separated.  Both  the  nuclei  and 
bodies  of  the  cells  in  cross  sections  appear  enlarged,  and,  in  longi- 
tudinal sections,  they  are  shorter  and  more  numerous.  Nearer 
the  ligature,  the  elastic  lamina  disappears,  and  capillary  loops, 
and  a  small  cell  growth  may  now  be  seen  crossing  the  media 
toward  the  axis  of  the  vessel.  Finally,  the  longitudinal  elastic 
fibres  are  separated  more  and  more  from  one  another,  and  the 
identity  of  the  media  is  completely  lost  in  the  granulation  tissue. 
The  intima,  above  and  around  the  thrombus,  shows  no  special 
change;  in  the  part  occupied  by  the  internal  callus  no  trace  of  it  is 
to  be  seen. 

Remarks. — We  have  here  an  example  of  unusual  inflammatory 
reaction.  A  softening  of  the  thrombus  has  been  produced,  but  this 
has  been  compensated  for  by  an  increased  development  of  callus, 
both  external  and  internal.  The  ends  of  the  vessel  have  retracted 
and  opened,  and  an  extensive  growth  of  granulation  tissue  has  found 
its  way  into  the  intima,  replacing  the  thrombus  as  it  breaks  down. 
The  activity  of  the  cells  of  the  media  is  specially  significant;  this  is 
not  a  simple  breaking  down  of  the  muscular  cells,  but  an  active 
participation  by  them  in  the  proliferation.     It  seems  but  natural  to 


78  TIic  Ligatiirc  of  Arteries. 

assume  that  these  cells  play  some  part  in  the  process  of  cicatrization. 
This  specimen  represents  the  reparative  process  well  advanced  in  its 
second  stage. 

Two  Months. 

One  month  after  the  ligature  was  applied  the  wound  reopened, 
and  a  small  sinus  continued  to  discharge  until  the  animal  was 
destroyed.  This  sinus  was  found  to  communicate  with  the  ligature, 
traces  of  which  could  still  be  seen. 

On  laying  open  the  vessel  by  a  longitudinal  section,  we  observe 
that  the  ends  of  the  vessel  have  retracted  some  distance  from  the 
ligature,  and  have  opened,  allowing  granulation  tissue  to  block  up 
the  lumen.  The  external  callus  is  about  two  and  a  half  inches  in 
length,  and  one  and  one  half  inches  wide.  The  internal  callus  oc- 
cupies about  three  quarters  of  an  inch  of  the  proximal  portion,  and 
one  half  inch  of  the  distal  portion.  Remains  of  the  thrombus  are  seen 
attached  to  these  growths  and  covering  them  like  a  scab.  (Fig.  2, 
Frontispiece.) 

In  the  proximal  portion  the  growth  extends  much  further  up  the 
sides  of  the  vessel  than  it  does  in  the  centre,  forming  a  cup-shaped 
end  to  the  lumen,  at  the  bottom  of  which  the  remains  of  the  throm- 
bus are  firmly  attached.  The  growth  is  covered  with  a  thickened 
layer  of  endothelium,  beneath  which  are  found  bundles  of  spindle- 
shaped  cells  with  long  staff-shaped  nuclei  closely  resembling  the 
muscular  cells  of  the  adjacent  media.  These  cells  occupy  the  upper 
part  of  the  internal  growth,  and  accompany  some  of  the  vessels  which 
dip  down  into  it.  There  are  a  good  many  capillary  vessels  ramifying 
in  a  hyaline  connective  tissue  which  fills  the  lower  part  of  the  callus. 
A  few  vessels  come  down  from  the  lumen;  the  communication  be- 
tween the  two  sets  is  not  yet  definitely  established.  No  marked  change 
is  seen  in  the  media.  The  connective  tissue  layer  of  the  intinia  can 
be  followed  with  the  other  coats  of  this  vessel.  The  shape  and  struc- 
ture of  the  internal  callus  of  the  distal  portion  areessentially  the  same 
as  that  found  in  the  proximal  end.  The  clot,  however,  extends 
more  deeply  into  the  new  tissue  below  it.  It  is  here  found  to  be 
composed  of  amorphous  and  more  or  less  fused  red-globules  and 
fibrine;  the  latter  being  either  fibrillated  or  "canalized."  Its  meshes 
are  more  or  less  completely  permeated  with  a  round  cell-growth.  The 
layer  of  muscular  cells  is  also  found  in  this  portion.  No  communi- 
cation of  the  vessels  of  the  granulation  tissue  with  those  coming  from 
l-he  lumen  is  seen. 


Experiments  on  Animals.  79 

j^t'Wrt^rAr.— This  specimen  affords  a  typical  example  of  the  exter- 
nal and  internal  callus  formation  at  the  height  of  their  development. 
The  expansion  of  the  ends  of  the  vessels  shows  the  ease  with  which 
granulations  may  enter  it.  The  incorrectness  of  the  term  "ulcera- 
tion of  the  ligature  "  is  exemplified  here.  There  has  been  no  ul- 
ceration or  cutting  action,  except  at  the  moment  of  ligature.  The 
inflammatory  process  set  up,  has  converted  the  adventitia  included 
in  the  ligature  into  soft  granulation  tissue,  thus  enabling  the  ends  of 
the  artery  to  retract,  and  leave  the  ligature  completely  isolated. 

The  growth  of  granulations  into  the  lumen  of  the  vessel  under- 
neath the  remains  of  a  blood-clot  closely  resembles  that  form  of 
reparative  process  which  is  usually  termed  "  healing  by  scabbing." 

Four  Months. 

The  ligature  was  applied  at  about  the  middle  of  the  common 
carotid.  This  experiment  was  performed  in  order  to  procure  a  speci- 
men of  the  fully  cicatrized  artery,  but,  on  removing  the  vessel,  it  was 
discovered  that  the  callus  had  not  yet  been  entirely  absorbed. 

The  ends  of  the  vessel  have  separated  from  one  another  about  an 
inch,  the  walls  have  expanded,  admitting  a  growth  of  tissue  which 
fills  about  one  half  an  inch  of  the  vessel  on  the  proximal  side  of  the 
ligature.  This  internal  growth,  on  the  distal  side,  is  about  an  inch 
and  a  half  in  length,  and  some  clot  is  still  adherent  to  it,  extending 
nearly  up  to  the  first  collateral  branch.  The  ligature  had  been 
placed  midway  between  two  branches  which  are  about  six  inches 
apart. 

The  internal  growth  consists  of  young  connective  tissue,  contain- 
ing many  long  spindle-shaped  cells  with  staft'-shaped  nuclei.  These 
are  seen  best  in  those  portions  which  extend  up  the  sides  of  the  ves- 
sel for  some  little  distance  beyond  the  central  portion  of  the  growth. 
There  is  a  thickened  covering  of  endothelium  over  the  new  tissue. 
Blood-pigment  is  found  in  this  tissue  in  abundance.  There  are 
several  blood-spaces  running  down  into  it  from  the  lumen,  so  that 
its  free  surface  presents  a  very  irregular  outline.  In  their  minute 
anatomy,  the  proximal  and  distal  ends  do  not  materially  differ  from 
one  another.  The  vascular  connection  between  the  blood-spaces, 
communicating  with  the  lumen,  and  the  arteries,  entering  the  end  of 
the  vessel  with  the  ingrowing  tissse,  is  evidently  established.  The 
tissue  at  the  point  of  its  entrance  into  the  vessel,  has  still  the  appear- 
ance of  a  granulation  tissue.      (Fig.  3.  Frontispiece.) 


8o  The  Ligature  of  Arteries. 

Remarks. — This  specimen  illustrates  the  very  slow  progress  which 
a  long  vessel  without  branches  makes  in  completing  the  healing  pro- 
cess, the  final  cicatrix  not  being  formed  until  the  portion  interven- 
ing between  the  branches  has  become  obliterated.  This  is  effected 
by  a  slow  growth  of  the  internal  callus  along  the  interior  of  the  ves- 
sel, and  by  the  retraction  and  contraction  of  the  walls  and  their  par- 
tial absorption. 

This  series  covers  the  period  beginning  with  a  well-formed  callus 
surrounding  the  ends  of  the  vessel,  still  firmly  closed  by  the  liga- 
ture, and  ending  with  the  stage  during  which  the  process  of  absorp- 
tion of  the  external  callus  is  far  advanced,  and  the  development  of 
the  final  tissue  which  is  to  form  the  permanent  cicatrix,  is  taking 
place. 

In  the  first  specimen,  we  see  the  stage  which  is  usually  taken  to 
represent  an  artery  after  ligature,  and  before  examining  the  later 
specimens,  it  would  appear  that  the  healing  process  had  been  com- 
pleted, and  the  ends  of  the  vessel-walls  firmly  moulded  into  a  con- 
tinuous layer  around  each  end  of  the  vessel;  but,  a  few  weeks  later, 
the  ends  of  the  vessel  have  unfolded,  and  in  Fig.  2,  of  the  fron- 
tispiece, we  see  the  full  development  of  the  second  stage  of  the  pro- 
cess of  repair.  The  interior  of  the  vessel  has  been  filled  with  a  mass 
of  inflammatory  tissue  directly  continuous  with  that  formed  outside, 
which  has  infiltrated  and  replaced  the  blood-clot,  now  largely  ab- 
sorbed. In  the  first  of  these  specimens,  there  is  no  change  noticed 
in  the  vessel-walls;  and  so  far  as  we  can  judge,  the  tissue,  found 
within  the  laminte  in  the  second  specimen,  emanates  directly  from 
the  granulation  tissue.  This  has  melted  down  the  fibres  which  held 
the  walls  together,  and  has  allowed  them  to  retract  and  to  permit  an 
entrance  of  the  active  cell-growth  to  the  interior.  These  facts  are 
obvious,  even  to  the  casual  observer,  and  a  careful  examination  with 
the  microscope  fails  to  show  that,  up  to  this  point,  the  coats  of  the 
vessel  have  taken  any  active  part  in  the  process.  No  thickening  of 
the  intima  can  be  found  to  account  for  the  presence  of  the  obliterat- 
ing tissue.  This  tissue  is  continuous  with  the  inner  coat,  the  cells  of 
which  may  participate  freely  in  the  reparative  process;  but  there  is 
no  marked  outgrowth  from  the  intima.  The  media  is  still  sharply 
defined  from  the  surrounding  mass  of  granulation-tissue,  but  its  cells 
have  already  begun  to  proliferate  and  to  prepare  for  their  participa- 
tion in  the  formation  of  the  ultimate  cicatrix.  The  tissue  of  the  in- 
ternal callus  projects  into  the  interior  in  irregular,  granulation-like 


Expcriuicnts  on  Animals.  8i 

masses  which  are  covered  by  the  remains  of  the  clot,  very  much  as 
the  dry  blood  of  a  wound  may  form  the  protecting  cover  of  a  granu- 
lating surface.  In  the  specimen  of  one  month,  the  inflammation  has 
been  sufficiently  severe  to  exaggerate  these  processes  greatly.  The 
external  callus  forms  a  spindle-shaped  mass  of  inflammatory  tissue 
nearly  half  a  foot  in  length;  the  thrombus  is  correspondingly  elon- 
gated, and,  at  several  points,  has  undergone  a  puriform  softening. 
The  conditions  are  favorable  for  a  breaking  down  of  the  material 
which  plugs  the  interior  of  the  vessel,  but  this  tendency  has  been 
overcome  by  the  excessive  callus  formation  which  has  penetrated  the 
interior  for  a  considerable  distance.  The  balance  between  the  sup- 
purative and  reparative  process  is  thus  maintained  to  an  extent  suffi- 
cient to  prevent  secondary  hemorrhage.  In  the  vessel,  tied  four 
months  previous  to  removal,  illustrated  in  drawing  3  of  the  frontis- 
piece, the  temporary  formations  are  in  process  of  absorption;  the 
ends  of  the  vessel  have  retracted  still  further  from  one  another,  and 
it  can  be  readily  seen  from  what  structures  the  band  of  tissue,  which 
unites  the  two  ends  of  a  ligatured  artery,  is  to  be  developed.  The 
internal  growth  fills  a  considerable  portion  of  the  interior  of  the  ves- 
sel, and  it  is  probable  that  this  growth  would  have  extended  still 
further  until  the  entire  trunk  had  become  obliterated  throughout  the 
space  intervening  between  two  large  branches.  The  final  formation 
of  the  cicatrix  is  thus  considerably  postponed  in  this  case  beyond  the 
average  time  of  most  arteries,  owing  to  the  unusual  length  of  the 
trunk.  A  differentiation  of  the  cell-elements  of  the  internal  callus 
is,  however,  already  taking  place,  and  cells,  closely  resembling  mus- 
cular cells,  can  be  seen  in  large  numbers.  A  study  of  the  walls  of 
the  vessels  involved  in  the  inflammatory  changes  suggests  that  an 
absorption  of  portions  of  the  various  coats  occurs  during  the  series  of 
changes.  The  separation  of  the  two  ends  of  the  artery  is  partly  due 
to  this  process,  and  partly  to  the  retraction  of  the  walls. 
6 


CHAPTER    III. 

MAN. 

LIGATURES    IN   CONTINUITY. 

The  following  specimens  have  been  selected  to  represent  the  most 
important  stages  in  the  process  of  repair,  and  include  most  of  the  ar- 
terial trunks  of  largest  size.  They  are  taken  from  the  collections  of 
the  Army  Medical  Museum  and  the  Warren  Museum  of  Anatomy, 
some  of  them  being  of  considerable  age,  and  some  prepared  within  a 
period  of  twenty-five  years.  Although  not  presenting  the  most  fav- 
orable conditions  for  microscopic  work,  the  histological  elements 
were  sufficiently  well  defined  by  careful  staining  to  determine  the 
nature  of  the  various  tissues  studied.  Some  of  the  preparations  of 
hematoxylin  gave  the  best  results,  although  carmine  and  the  aniline 
dyes  were  also  used,  the  sections  being  mounted  both  in  Canada  bal- 
sam and  glycerine. 

In  all  the  specimens  examined,  embracing  the  period  during 
which  the  callus  is  to  be  found,  this  structure  had  been  dissected 
away,  showing  the  vessel  either  as  it  would  appear  directly  after 
application  of  the  ligature;  that  is,  as  a  hollow  cylinder,  constricted 
at  one  point  by  a  knot,  or  as  two  fragments  slightly  separated  from 
one  another,  but  held  together  by  a  narrow  cord.  Both  of  these 
results  had  been  obtained  by  dissecting  away  the  callus.  It  needs 
but  a  glance  at  the  three  specimens  of  the  carotid  artery  of  the 
horse,  shown  in  the  frontispiece,  to  be  convinced  of  the  superiority 
of  the  method  there  employed  for  displaying  the  vessel  to  the  best 
advantage.  All  results  of  pathological  changes  have  been  preserved, 
and  the  specimen  is  divided  into  halves  by  a  longitudinal  section. 
In  several  of  the  preparations  selected  for  study,  the  interior  of  the 
vessel  had  never  been  displayed,  and  their  value  was  greatly  enhanced 
by  treatment  in  this  manner,  a  portion  being  obtained  at  the  same 
time  for  microscopical  examination. 

Although  the  evidence  of  the  existence  of  a  callus  had  been  de- 
stroyed by  the  dissection,  the  descriptions  in  some  cases  gave  most 


Man.  83 

satisfactory  testimony  to  the  existence  of  such  a  structure.  A  refer- 
ence to  the  description  of  specimen  1684,  Army  Medical  Museum, 
shows  that  the  ends  of  the  vessel  at  the  point  of  ligature  were  im- 
bedded in  a  callus  of  very  considerable  size. 

COMMON   CAROTID   ARTERY. 
Four  Days. 

Specimen  No.  1748,  Warren  Museum. — L.  C,  Female,  set.  32, 
presented  herself  at  the  Massachusetts  General  Hospital  in  August, 
1857,  with  a  "vascular  encephaloid  tumor  of  left  temple,  involving 
orbit  and  cranial  cavity."  The  left  common  carotid  was  tied  August 
8th;  the  right  common  carotid  was  tied  August  i8th;  the  patient  died 
August  22d. 

The  ligature  of  the  right  carotid  was  placed  a  little  below  the 
point  of  bifurcation.  On  laying  open  the  specimen  longitudinally, 
a  large  thrombus  was  found  below  the  point  of  ligature  distending 
the  vessel  in  an  ampulla-like  shape  near  the  ligature,  and  filling  about 
one  half  the  length  of  the  vessel,  growing  gradually  smaller  and 
being  firmly  attached  to  the  walls  in  its  entire  length,  except  at  the 
small  cone-shaped  apex.  It  proved  to  be  a  hard  and  extremely  dark 
colored  clot.  The  distal  thrombus  w-as  much  smaller,  more  friable, 
and  lighter  in  color,  a  great  deal  of  it  dropping  out  on  opening  the 
vessel.  .  It  extended  up  the  internal  carotid  beyond  the  end  of  the 
portion  of  the  artery  preserved. 

Proximal  Portion. — At  the  point  of  ligature,  a  low  power  shows 
both  the  intima  and  media  ruptured;  the  former  being  torn  entirely 
through  on  one  side,  and  about  two  thirds  on  the  other.  The  adven- 
titia  is  collected  into  a  dense  and  thick  bundle  of  fibres  by  the 
ligature,  and  does  not  appear  to  have  been  injured.  There  is  no 
marked  curling  up  of  the  broken  ends,  but  they  appear  frayed 
out  and  are  entangled  in  the  clot.  The  walls  are  distended  by 
the  thrombus  at  the  point  corresponding  to  its  base,  and  are  in 
consequence  much  thinner  than  normal.  The  media  is  especially 
thinned. 

The  intima,  which  in  this  vessel  has  quite  a  thick  connective 
tissue  layer,  terminates  on  either  side  in  a  tapering  point  at  the  edge 
of  the  ruptured  media.  There  is  no  change  in  this  layer  near  the 
ligature;  a  number  of  white  corpuscles,  grouped  together  at  various 
points,  cling  to  it,  but  they  seem  to  belong  to  the  thrombus.  A 
large  number  of  leucocytes  are  collected  between  the  ruptured  edges 


84  The  LigatJire  of  Arteries. 

of  the  media,  and  are  entangled  in  fibrine-fibres.  These  together 
form  quite  a  mass,  filling  the  central  third  of  the  thrombus  for  some 
distance.  The  thrombus  is  irregularly  laminated,  and  has,  when 
seen  with  a  low  power,  a  marbled  appearance,  the  irregular  arrange- 
ment of  the  fibrine  and  white  corpuscles,  which  are  always  together, 
breaking  the  mass  of  red  corpuscles  up  into  lobules  of  varying  size. 
The  clot  is  exceedingly  tough  and  difficult  to  cut  with  the  micro- 
tome, owing  apparently  to  its  density.  It  terminates  in  a  short  pyra- 
midal apex  consisting  of  fibrine  and  white  corpuscles.  The  walls  of 
the  vessel  throughout,  except  at  this  terminal  point,  are  adherent  to 
it,  and,  as  the  throml)us  diminishes  considerably  in  circumference 
in  its  lower  half,  are  much  contracted  at  this  point.  Near  the  apex 
there  is  a  marked  thickening  of  the  intima,  showing,  under  a  high 
power,  a  growth  of  spindle  and  round  cells,  which  project  into  the 
clot  a  short  distance,  and,  when  broken  away  from  it,  present  a 
serrated  edge.  Nowhere  else  is  any  such  change  in  the  intima 
found.  There  is  little  change  seen  in  the  walls  of  the  distal  portion. 
A  small  fragment  of  clot,  composed  of  red  corpuscles,  adheres  still  to 
the  ruptured  surface.  There  is  not  the  same  ragged  surface  as 
upon  the  proximal  side  of  the  ligature,  but  the  vessel  appears  to  be 
thrown  into  a  series  of  folds  radiating  from  the  ligature.  The  ap- 
pearances of  both  sides  of  the  ligature  closely  resemble  those  shown 
in  Fig.  2.  Following  the  walls  of  the  vessel  higher  up,  a  slight 
thickening  of  the  intima  is  observed  at  the  bifurcation  of  the 
vessel  on  the  sides  opposite  the  angle,  a  point  where  a  portion  of 
this  thrombus  ends. 

Remarks. — In  this  specimen  all  external  callus  has  been  dissected 
away  in  accordance  with  the  usual  method  of  preparation.  It  is  an 
interesting  fact  that  no  signs  of  new  tissue-formation  are  to  be  found 
within  the  vessel,  except  at  a  point  quite  remote  from  the  ligature. 
The  growth  in  the  intima  near  the  apex  of  the  thrombus  both  favors 
the  narrowing  of  the  lumen,  and  serves  to  hold  the  thrombus  firmly 
in  place.  Is  such  a  growth  to  be  regarded  as  of  traumatic  origin,  or 
simply  as  a  formative  process  intended  to  adapt  the  parts  to  new 
conditions  ? 

There  is  evidently  a  true  dilatation  of  the  proximal  end  of  the 
vessel,  for  the  walls  are  put  upon  the  stretch,  and  much  thinned; 
the  appearance  is  not  produced  by  the  contraction  of  the  vessel 
below. 

The  appearance  of  the  distal  portion  of  the  vessel  at  the  point  of 
ligature  is  the  one  usually  seen.     The  fact  that  the  ruptured  edges 


Man.  85 

of  the  media  are  not  seen  is  due  to  the  collapse  of  the  vessel,  or 
rather  to  the  lack  of  distension  of  this  portion. 

COMMON    CAROTID    ARTERY. 
Fifteen  Days. 

This  vessel  was  also  part  of  specimen  1748.  The  ligature  had 
been  placed  very  high  on  the  left  common  carotid.  The  proxi- 
mal thrombus  extended  nearly  to  the  aortic  arch;  the  distal  was 
very  small,  being  confined  to  the  main  trunk  only:  both  thrombi 
were  very  friable  and  unattached,  and  dropped  out  on  opening  the 
specimen. 

Longitudinal  sections  show  that  the  iwner  coat,  which  in  the 
common  carotid  is  of  unusual  thickness,  has  not  been  divided,  but 
is  continuous  through  the  ligatured  point;  beyond  a  slight  bruise  at 
one  spot,  no  injury  has  been  done  to  it  by  the  application  of  the 
ligature.  The  media  and  adventitia  have,  on  the  other  hand,  been 
completely  separated,  probably  by  the  softening  effect  of  the  cell 
infiltration.  A  cell-growth  is  found  in  the  inner  layers  of  the  ends 
of  the  media;  loosening  its  fibres  and  dissecting  up  the  intima  so 
that,  at  the  proximal  end,  this  coat  is  raised  up  like  a  vesicle.  There 
appears  to  be  no  change  in  the  elements  of  the  intima,  which,  in 
this  trunk,  consists  of  quite  a  thick  layer  of  longitudinal  fibres. 
In  the  lumen  of  the  vessel  on  either  side  of  the  ligature,  there  is 
no  evidence  whatever  of  any  repair.  Such  external  callus  as 
existed  has  been  dissected  away  in  preparing  the  specimen  for  the 
Museum. 

Remarks. — The  process  of  repair  seems  to  have  been  arrested, 
probably  by  a  suppuration  and  softening  of  the  external  callus. 
There  is  insufficient  provisional  growth  to  replace  the  retracting 
outer  coats.  The  non-adherence  of  the  thrombus  is  probably  due  to 
the  lack  of  rupture  of  the  intima.  In  the  right  carotid,  it  will  be 
remembered  that  the  inner  coats  were  ruptured,  and  the  thrombus 
firmly  attached.  Secondary  hemorrhage  from  the  distal  end  could 
not  have  been  long  delayed  had  the  patient  lived.  It  is  particularly 
worthy  of  note  that  no  tissue  is  found  growing  from  the  intima,  al- 
though unusual  facilities  exist  for  studying  that  tunic. 

The  second  stage  of  the  process  of  repair  is  beginning.  The 
outer  walls  have  released  themselves  from  the  ligature,  and  granula- 
tion tissue  is  about  to  penetrate  the  inner  coat,  which  in  this  case 
has  not  been  ruptured. 


86  Tlic  Ligature  of  Arteries. 

SUBCLAVIAN    ARTERY. 

Forty-six  Days. 

Specimen  1684,  Army  Medical  Museum. — The  specimen  is  thus 
described  in  the  catalogue  of  the  Museum  : 

"A  wet  preparation  of  the  left  subclavian  artery,  forty-six  days  after  ligation  in 
the  third  portion,  for  traumatic  aneurism  of  the  axillary,  after  gunshot,  and  twenty- 
eight  days  after  the  ligature  came  away.  Capt.  T.  F.  J.,  "  B,"  13  Va.  Cavalry 
(Rebel)  31."  A  carbine  ball  passed  through  the  brachial  plexus  of  nerves,  and  cut 
the  axillary  artery  one  and  one  half  inches  above  its  termination.  Middleburg,  Va., 
2ist  June:  admitted  hospital,  Washington,  23d  June;  a  circumscribed  traumatic 
aneurism  at  the  seat  of  injury  appeared  12  July:  subclavian  ligated  at  the  external 
border  of  the  scalenus  by  surgeon  John  A.  Lidell,  U.  S.  Vols.  14th.  Aneurismal 
sac  opened  spontaneously  19th  July;  ligature  separated  without  hemorrhage  ist 
August;  profuse  hemorrhage  from  the  sac  arrested  by  injection  of  solution  of  per- 
sulphate of  iron,  6th;  hemorrhage  recurred  loth,  nth  and  i8th;  died,  exhausted  with 
suppuration  and  hemorrhage,  igth  August,  1863." 

The  point  of  ligature  is  represented  by  a  ligamentous  band  about 
one  quarter  of  an  inch  in  length,  but  this  is  evidently  an  artificial 
production,  for  it  is  stated  by  Dr.  Lidell,  in  his  account  of  the  case 
(Surgical  History  of  the  War,  Part  First,  p.  544),  that  the  artery  on 
each  side  of  the  ligature,  "  is  surrounded  by  a  dense  mass  of  new 
connective  tissue,  so  thick  and  dense  as  to  make  it  a  little  difficult 
to  get  at  and  remove  the  specimen  without  injury."  Evidently 
there  was  a  large  external  callus  which  had  been  dissected  away. 
The  vessel  was  not  open,  but  it  was  evident  that  there  was  a  throm- 
bus of  considerable  size  in  the  proximal  portion,  which  for  the  space 
of  over  an  inch,  gave  off  no  branch.  The  specimen  was  opened  in 
such  a  way  that  a  longitudinal  section  was  made  through  both  the 
ends  of  the  vessel  without  any  injury  to  the  connecting  band,  the 
parts  removed  being  used  for  microscopical  examination.  The 
lumen  of  the  proximal  portion  appeared  to  be  occupied  by  a  throm- 
bus about  three  quarters  of  an  inch  in  length,  filling  out  the  vessel 
to  nearly  its  full  size,  and  tapering  off  in  an  elongated  point  on  the 
side  opposite  the  origin  of  the  first  branch.  On  the  distal  side,  the 
process  of  cicatrization  seemed  to  be  complete;  a  small  thread-like 
fragment  of  clot  still  hanging  from  one  portion  of  the  cicatrix. 

Proximal  End. — On  microscopical  examination  it  is  seen,  that 
most  of  the  thrombus  has  become  "organized;"  that  is,  has  been 
replaced  by  new  tissue.     There  is  still  a  laminated  clot  lying  upon 


Ma7i.  87 

this  tissue,  tapering  off  on  one  side,  as  has  been  described,  where  it 
is  firmly  held  by  what  appears  to  be  a  growth  arising  from  the  longi- 
tudinal fibres  of  the  intima.  The  new  tissue  constituting  the  in- 
ternal callus,  varies  somewhat  in  appearance:  in  places  it  is  com- 
posed of  spindle  and  stellate  cells  in  a  hyaline  matrix;  at  others,  of 
ordinary  granulation  tissue;  at  others  still,  there  is  a  considerable 
amount  of  blood  pigment,  and  here  and  there,  are  to  be  found  frag- 
ments of  still  unabsorbed  clot.  The  tissue  has  a  cavernous  appear- 
ance due  to  the  presence  of  numerous  blood-spaces,  the  borders  of 
which  are  lined  with  a  delicate  endothelium.  There  are  also  a 
number  of  capillary  vessels  ramifying  in  the  new  tissue;  whether 
these  communicate  with  the  blood-spaces  or  not,  cannot  be  deter- 
mined. Near  the  point  of  ligature,  the  tissue  is  in  a  crumbling 
state,  due  probably  to  suppuration.  The  coats  of  the  artery  have 
separated  here,  admitting  freely  the  granulation  tissue,  which  sup- 
plies probably  the  greater  portion  of  the  new  growth,  of  which  the 
internal  callus  consists.  It  is  probable  also  that  some  tissue  is 
formed  by  the  intima,  a  growth  from  which  near  the  apex  of  the 
thrombus  has  already  been  mentioned,  but  the  longitudinal  fibres 
can  be  traced  down  on  either  side  of  the  vessel  nearly  to  the  point 
of  ligature. 

Distal  Efid. — The  conditions  here  are  in  striking  contrast  to 
those  described  above.  The  process  of  repair  seems  to  have  been 
completed.  The  walls  of  the  vessel,  as  seen  in  longitudinal  section, 
are  slightly  separated,  and  the  space  thus  left  is  occupied  by  a  mass 
of  cicatricial  tissue  which  runs  symmetrically  upon  the  sides  of  the 
vessel  for  a  short  distance.  It  is  composed  chiefly  of  spindle  and 
stellate  cells,  the  former  running  chiefly  in  bundles  parallel  to  the 
surface  of  the  cicatrix,  the  latter  being  imbedded  in  a  hyaline  inter- 
cellular substance.  The  cicatrix  is  pierced  by  a  central  vessel,  the 
route  of  which  can  not  be  definitely  ascertained.  It  probably  com- 
municates with  capillaries  in  the  granulation  tissue,  which  can  still 
be  seen  lying  beneath  the  tissue  just  described,  and  blocking  the 
mouth  of  the  vessel.  The  filamentous  clot  is  of  about  the  thickness 
of  a  silk  ligature,  and  is  one  inch  in  length. 

Remai-ks. — The  proximal  end  of  this  specimen  illustrates  the 
process  of  repair  as  seen  at  about  the  end  of  six  weeks.  The  vessel- 
walls  have  separated  and  retracted,  and  an  abundant  growth  of  tissue 
has  penetrated  and  absoriied  the  thrombus.  What  may  be  called 
the  second  stage  of  the  process  of  repair  is  here  represented  at  its 
height  of  development,  a  large  external  and   internal  callus  having 


88  TJie  Ligature  of  Arteries. 

been  formed.  It  is  probable  that,  in  a  large  arterial  trunk  like 
this,  a  greater  portion  of  the  internal  growth  of  the  proximal  portion 
will  be  permanent,  presenting  appearances  closely  resembling  those 
shown  in  Fig.  27.  The  distal  portion  is  an  example  of  a  nearly  com- 
pleted permanent  cicatrix.  The  early  termination  of  the  reparative 
process,  here  may  be  due  to  the  presence  of  a  branch  of  considera- 
ble size,  preventing  the  development  of  a  large  thrombus  or  callus; 
in  other  words,  of  provisional  tissues,  which  would  require  time  for 
their  absorption.  The  secondary  hemorrhage  was  evidently  sup- 
plied from  collateral  sources. 

A  careful  examination  shows  but  a  slight  growth  from  the  intima. 
This  has  been  sufficient  in  the  proximal  portion  to  attach  the  end  of 
the  clot  firmly  to  the  wall,  but  it  is  probable  that  only  an  insignifi- 
cant portion  of  the  cell-structure  found  in  the  interior  of  the  vessel 
at  this  end  has  l)een  supplied  from  this  layer. 

FEMORAL   ARTERY. 

Fifty-five  Days. 

Specimen   3983,   Army  Medical   Museum,   is  thus  described: 

"  Wet  preparation  of  portion  of  external  iliac,  femoral,  profunda  and  anastomo- 
tica  magna,  with  the  femoral  ligated  in  its  continuity  for  secondary  hemorrhage." 
The  injury  was  a  gunshot  fracture  of  the  bones  of  the  leg,  for  which  amputation  in 
the  upper  third  of  the  leg  was  performed,  Dec.  4,  1862.  Re-amputation  was  per- 
formed at  the  junction  of  the  middle  and  lower  thirds  of  the  femur  on  January  15th; 
the  femoral  was  tied  February  4th,  and  death  occurred  March  31st,  1863. 

The  specimen  was  so  arranged  that  the  relations  of  the  vessel  in 
reference  to  the  point  of  ligature  were  not  easily  made  out.  The 
proximal  and  distal  ends  were  apparently  drawn  forward  into  the 
cicatrix,  in  such  a  way  as  to  be  nearly  parallel  to  one  another.  The 
whole  vessel  was  greatly  diminished  in  calibre,  although  the  distal 
was  larger,  at  the  point  of  ligature,  than  the  proximal  end.  An 
attempt  had  been  made  to  inject  the  specimen,  which  rendered  the 
cutting  of  microscopical  sections  difficult.  One  half  of  each  end 
was  reserved  for  this  purpose,  and  sections  were  made  longitudin- 
ally. 

Proximal  Etui. — The  vessel  is  much  contracted,  and  gradually 
narrows  to  a  somewhat  sharp  end  at  the  cicatrix,  where  it  is  united 
to  the  distal  portion  by  a  ligamentous  band  of  fibres.  The  walls  of 
the  vessel  have  slightly  separated  at  the  point  of  ligature,  admitting 


Man.  89 

a  growth  of  tissue  from  without.  The  amount  is  sUght,  and  there 
is  a  sHght  thickening  of  the  intima  on  either  side  as  far  as  the  sec- 
tion goes:  there  is  no  thrombus. 

Distal  Portion. — Tliis  end  presents  characteristics  one  would 
have  expected  to  find  on  the  proximal  side  of  the  ligature,  but  it 
could  not  be  made  out  from  a  careful  study  of  the  specimen,  to  be 
other  than  the  distal  portion.  The  lumen  is  larger  than  at  the 
proximal  end,  and  terminates  as  a  cul-de-sac:  it  is  filled  by  a  throm- 
bus about  one  and  one  half  inch  in  length.  The  walls  at  the  end  of 
the  vessel  are  slightly  separated,  and  between  them  is  found  some 
connective  tissue  and  pigment  cells,  beyond  which  within  the  lumen 
is  a  cup-shaped  mass  of  hyaline  tissue  in  which  are  imbedded  spin- 
dle and  stellate  cells.  There  are  numerous  small  vessels  in  this 
tissue  which  are  seen  to  communicate  by  at  least  two  branches  with 
the  vessel.  A  vessel  also  runs  between  the  separated  walls,  to  com- 
municate with  the  external  tissue  beyond:  they  are  all  filled  with  the 
material  used  for  the  injection.  There  is  calcareous  degeneration 
of  the  media  in  both  portions  of  the  vessel. 

Retnarks. — We  have  here  conditions  resulting  from  ligature  in  an 
amputation  stump,  followed  by  a  ligature  in  continuity.  The  con- 
traction of  the  vessel  had  begun  at  the  time  of  the  first  amputation, 
nearly  four  months  before  death.  The  cicatrix  at  the  distal  end  is 
a  typical  example  of  the  cicatrix  from  ligature  in  continuity,  but 
there  is  also  a  thickening  of  the  intima  which  foreshadows  the  devel- 
opment of  the  obliterating  process  in  the  large  vessels  of  a  stump. 

EXTERNAL    ILIAC  ARTERY. 

One  Hundred  and  Thirty  Days. 

Specimen  3986,  Army  Medical  Museum. — The  Catalogue  thus 
describes  it: 

"A  wet  preparation  of  right  and  left  common,  external  and  internal  iliac  arter- 
ies eighteen  weeks  after  ligature  of  the  right  external  iliac  for  traumatic  aneurism. 
The  specimen  shows  the  ligated  artery  diminished  to  a  small  cord,  and  the  corre- 
sponding internal  branch  much  enlarged.  Private  J.  R.L.  '  F  '  loth  Georgia  (Rebel) 
19:  ball  passed  through  the  right  thigh,  from  front  to  rear,  half  an  inch  below  Pou- 
part's  ligament,  17th  September;  admitted  hospital  with  wound  closed,  but  with  an 
aneurismal  tumor  in  groin,  Frederick,  27th  October;  external  iliac  ligated  above  the 
circumflex  and  epigastric  by  Assistant-Surgeon  R.  F.  Weir,  U.  S.  Army,  6th 
November;  slight  attack  of  hospital  gangrene,  25th  November,  1862;  an  abscess 
near  the  cicatrix  discharged  2d   March;  arterial    hemorrhage,    seven  ounces,  sac 


go  Tlie  Ligatiwe  of  Arteries. 

opened,  femoral  necessarily  cut,  but  without  loss  of  blood:  no  vessel  could  be 
found,  and  death  occurred  from  previous  hemorrhage  and  shock  of  operation, 
March  i6th. 

An  examination  of  the  specimen  shows  a  cordhke  mass  spring- 
ing from  a  small  pouch  remaining  at  the  angle  of  division  of  the 
external  and  internal  iliac  arteries.  The  femoral  artery  has  been 
laid  open  and  disconnected  from  the  other  end  of  the  cord,  so  that 
it  was  not  possible  to  study  the  distal  end  of  the  vessel.  The  cica- 
trix at  the  proximal  end  was  removed  for  microscopical  examina- 
tion, longitudinal  sections  being  made  through  it,  and  subjected  to 
the  double  staining  of  eosine  and  hematoxylin.  The  walls  of  the 
vessel  are  slightly  separated,  admitting  between  them  some  of  the 
fibres  of  the  cord:  the  media  becomes  here  irregular  and  broken  in 
appearance,  and  gradually  tapers  off  and  is  lost  in  the  cord.  The 
latter  structure  consists  of  longitudinal  fibres  intermingled  with  con- 
nective tissue  cells  and  pigment  granules.  Just  within  the  vessel- 
walls  there  is  a  crescentic-shaped  mass  of  hyaline  cicatricial  tissue, 
the  horns  of  which  taper  off  symmetrically  on  either  side  of  the  wall 
a  short  distance  beyond.  It  consists  of  a  transparent  homogeneous 
intercellular  substance  in  which  are  found  spindle  and  stellate  cells. 
The  spindle-cells  are  exceedingly  long  with  delicate  tapering  ends 
and  elongated  nuclei:  they  are  found  singly  and  in  bands,  and  are 
arranged  parallel  to  the  walls  of  the  vessel;  that  is,  more  or  less 
longitudinally  and  also  circularly.  This  tissue  lies  upon,  but  is  dis- 
tinct from,  the  tissues  of  the  cord.  At  one  point  the  lamina  elastica 
is  broken,  and  a  number  of  cells  are  seen  growing  from  the  media 
into  the  new  cicatricial  tissue.  A  small  central  vessel  is  seen  break- 
ing up  into  one  or  two  capillaries  which  run  in  the  direction  of  the 
cord.  The  cicatrix  is  covered  with  a  delicate  layer  of  endothelium. 
(Frontispiece,  Plate  II.) 

Remarks. — This  is  a  typical  example  of  a  cicatrized-  arterial 
trunk.  It  has  been  converted  into  a  cord  of  fibrous  tissue.  The 
internal  cicatrix  is  a  shallow  one,  contrasting  in  this  respect  with 
that  seen  in  the  subclavian  artery,  and  in  the  common  carotid 
artery,  the  report  of  which  follows.  This  is  explained  probably 
by  the  absence  of  any  direct  blood  pressure  upon  the  spot,  such 
as  must  have  been  sustained  in  those  cases.  It  amounts  to  a 
cicatrix  in  the  wall  of  a  large  arterial  trunk,  and  not  at  the  end  of  a 
cul-de-sac. 

The  delicate  tissue,  which  forms  this  cicatrix,  is  beautifully 
shown,  in  spite  of  the  age  of  the  specimen,  and  there  can  l)e  little 


Man.  91 

doubt,  that  many  of  its  elements  are  of  a  muscular  character.  How- 
else  can  we  explain  the  immunity  of  such  a  scar  from  aneurismal 
dilatation?  The  healing  process  is  complete;  all  provisional  struc- 
tures have  disappeared,  and  the  parts  are  now  in  the  form  in  which 
they  would  have  remained  permanently.  We  have  in  this  specimen 
an  indication  of  the  full  time  required  for  the  completion  of  the 
healing  process  in  vessels  of  the  largest  size. 

COMMON   CAROTID  ARTERY. 
Four  Years. 

Specimen  No.  1749,  Warren  Museum.  The  specimen  is  an  old 
one,  having  been  in  alcohol  about  fifty  years.  It  came  from  a 
patient  who  was  said  to  have  died  of  phthisis  four  years  after  ligature 
of  the  common  carotid  in  continuity;  for  what  disease  was  not 
stated . 

The  two  ends  of  the  artery  are  separated  widely  from  one  an- 
other, a  long  and  slender  band  of  connective  tissue  connecting  them 
together.  The  cicatrix  in  the  proximal  end  is  about  one  inch  in  length 
terminating  at  a  point  about  half  an  inch  from  the  aorta.  It  has  a 
pigmented  look,  and  might  easily  be  mistaken  for  a  shrunken  throm- 
bus, seen,  as  it  is,  through  a  slit  in  the  side  of  the  vessel.  Its  sur- 
face forms  an  inverted  cone  presenting  towards  the  aorta;  the  apex 
of  the  cone  is,  however,  not  in  the  centre  of  the  vessel,  but  a  little 
on  one  side;  probably  the  side  farthest  from  the  heart.     (Fig.  27.) 

The  slit  in  the  vessel  was  closed  with  a  stitch  and  that  portion 
containing  the  cicatrix  was  removed  entire,  for  the  purpose  of  mak- 
ing horizontal  sections.  As  will  be  seen  in  Fig.  27,  the  walls  are 
well  defined,  and,  at  the  end  of  the  vessel,  are  slightly  patulous. 
Just  outside  is  the  tissue  of  the  cord  which  terminates  abruptly  at 
the  opening  in  the  vessel.  At  this  point  some  fragments  of  the 
media  may  be  seen,  which  probably  represent  portions  of  the  oblit- 
erated artery. 

Within  the  vessel  is  an  extremely  delicate  and  spongy  tissue, 
filled  with  blood-spaces,  which  communicate  with  the  lumen,  and 
also  with  capillaries  and  arterioles,  which  appear  to  spring  from  the 
large  blood -spaces,  for  they  branch  in  the  direction  of  the  cord,  and 
not  of  the  lumen;  they  are  also  seen  to  communicate  freely  with  the 
blood-channels. 

The  surface  of  the  cicatrix  is  covered  with  a  layer  of  endothelium 
which  may  be  traced  down,  into  the  various  spaces. 


92  Tlic  Ligature  of  Arteries. 

Just  below  the  surface  there  is  a  layer  of  fibres  running  parallel 
with  it,  consisting  probably  of  spindle-shaped  or  muscular  cells. 
The  age  of  the  specimen  prevents,  however,  a  satisfactory  staining 
of  this  portion.  Long  muscular  cells  with  glistening  tape-like  bodies 
and  elongated  nuclei  are  found  in  many  parts  of  the  cicatricial  tissue. 
In  its  deeper  portion  the  character  of  the  tissue  differs  from  that 
seen  on  the  surface.  We  find  here  stellate  anastomosing  cells  and 
round  cells  lying  in  clear  homogeneous  or  slightly  fibrillated  inter- 
cellular substance,  in  which  are  also  found  numerous  masses  of 
blood  pigment.  It  is  in  this  part  of  the  cicatrix  that  the  large 
cavernous  spaces  are  most  numerous.  These  latter  are  surrounded 
with  a  thin  wall  of  muscular  cells,  and  lined  with  endothelium. 
Some  glistening  bands,  looking  like  elastic  fibres,  run  somewhat  ir- 
regularly in  a  longitudinal  direction.  In  this  neighborhood,  near  the 
termination  of  the  vessel  in  the  cord,  the  new  tissue  is  much  less 
vascular,  and  no  large  channel  of  communication  with  outside  capil- 
laries is  found. 

The  longitudinal  fibres  of  the  intima  can  be  traced,  along  the 
inner  wall  of  the  vessel,  into  the  cicatrix,  where  they  do  not  lose 
themselves,  but  continue  on  as  far  as  the  media  goes,  forming  a  layer 
separate  and  distinct  from  the  cicatricial  tissue. 

The  cicatrix  in  the  distal  portion  is  much  shorter  and  terminates 
in  a  funnel-shaped  end.  It  extends  much  farther  up  one  side  of  the 
vessel  than  on  the  other,  in  fact,  into  the  external  carotid,  growing 
slightly  thicker  opposite  the  first  branch  given  off,  probably  the 
superior  thyroid.  (Fig.  27.)  There  is  no  essential  difference  in 
the  histological  details  of  the  tissue  from  that  already  described  in 
the  proximal  portion. 

Remarks. — As  the  result  of  ligature  there  has  been  an  almost 
complete  obliteration  of  the  common  carotid  artery.  This  has  been 
accomplished  partly  by  a  filling  up  of  the  calibre  with  cicatricial 
tissue,  partly  by  a  disintegration  and  absorption  of  the  walls,  and 
partly  by  a  retraction  of  the  ends  of  the  vessel  from  the  point  of 
ligature. 

The  long  cicatrix  of  the  proximal  end,  with  its  numerous  and 
tortuous  sinuses,  surrounded  and  supported  by  muscular  cells,  is 
well  calculated  to  support  the  great  pressure  that  must  have  been 
brought  to  bear  upon  it  with  every  pulsation  of  the  heart.  It  prac- 
tically represents  a  long  and  tortuous  blood-vessel,  coiled  up  in  a 
small  space,  and  gradually  terminating  in  a  capillary  system.  Had 
the  ligature  been  placed  on  the  right  common  carotid,  we  should 


Man.  93 

probably  have  had  a  cicatrix  more  Uke  that  found  in  the  external 
iliac  artery,  the  force  of  the  blood  current  being  diverted  into  a  col- 
lateral system  of  vessels.  In  the  present  case  we  have  what  may  be 
regarded  as  a  gradual  narrowing  down  of  the  lumen  of  the  vessel, 
thus  preventing  a  too  abrupt  obstruction  to  the  blood-current. 

The  specimens  here  described  illustrate  repair  in  the  first  week, 
at  the  end  of  two  weeks,  at  the  end  of  six  weeks,  at  two  months, 
at  four  months,  and  at  the  end  of  four  years.  Two  of  them  belong 
to  the  first  period  of  the  process,  two  to  the  second,  and  two  are 
typical  examples  of  the  final  cicatrization  when  the  series  of  changes 
has  terminated  by  the  formation  of  a  tissue  which  is  permanent  in 
character. 

A  comparison  with  the  series  of  specirnens  showing  repair  in 
dogs  and  horses  brings  out  no  essential  points  of  difference.  The 
preparation  of  the  common  carotid  four  days  after  ligature  is  almost 
a  counterpart  of  that  representing  the  same  period  in  the  dog. 
Fig.  2  might  serve  equally  well  for  either.  The  external  granula- 
tion tissue  represented  in  the  drawing  has  of  course  been  dissected 
away  in  the  Museum  specimen,  but  we  note  in  both  the  ampulla-like 
dilatation  of  the  proximal  end  of  the  vessel  and  the  consequent 
stretching  of  the  wall,  which  makes  it  appear  much  thinner  than 
that  on  the  distal  side  of  the  ligature.  In  some  cases  this  appeared 
as  a  distinct  dilatation  of  the  end  of  the  vessel  with  blood,  as  if  it 
had  been  packed  into  this  cul-de-sac  with  considerable  force  by  the 
pressure  of  the  blood  column.  The  arterial  walls  are  ruptured 
internally  to  about  the  same  extent,  that  is  through  the  media  to  its 
outermost  layer.  The  rupture  does  not  always  extend  to  the  ad- 
ventitia,  although,  when  the  knot  is  firmly  tied  and  then  removed, 
allowing  the  blood  to  expand  the  vessel  again,  longitudinal  sections 
show  a  rupture  extending  to  the  adventitia,  as  was  evidently  the  case 
in  Fig.  25.  The  fibres  of  the  outer  coat  are  collected  into  a  tendon- 
like band  which  appears  to  be  sufficiently  enduring  to  resist  the 
pressure  of  the  tightest  knot:  this  is  the  case  in  the  human  specimen, 
as  well  as  in  animals.  The  inner  coat  of  the  common  carotid  is 
much  thicker  in  man,  and  consists,  in  addition  to  the  endothelium,  of 
a  thick  layer  of  longitudinal  fibres.  Occasionally  these  escape  rup- 
ture, as  in  the  case  of  the  carotid  of  fifteen  days.  In  this  specimen 
both  the  media  and  adventitia  have  retracted  slightly,  and  released 
themselves  from  the  knot;  it  is  not  therefore  possible  to  say  whether 
the  media  was  ruptured  by  the  ligature  or  not,  as  the  separation  of 


94  TJie  Ligature  of  Arteries. 

this  coat  might  be  due  to  the  solvent  action  of  the  granulation  cells 
which  have  already  disposed  of  the  outer  coat.  It  is  interesting  to 
observe  in  connection  with  the  preservation  of  the  intima,  and  the 
consequent  al)sence  of  favorable  points  of  attachment,  that  the 
thrombus  was  not  adherent  to  the  wall,  and  fell  out  on  opening  the 
specimen.  In  neither  of  these  vessels  is  there  any  evidence  of  repair 
taking  place  in  the  interior  of  the  artery,  if  we  except  the  growth 
from  the  intima  at  the  apex  of  one  thrombus,  a  point  some  distance 
removed  from  the  region  of  cicatrization.  Such  a  growth  seems  to 
serve  the  purpose  merely  of  attaching  the  thrombus  to  the  vessel  at 
a  point  whence  fragments  might  readily  be  dislodged  and  carried  off 
into  the  circulation.  There  did  not  appear  to  be  any  injury  to  the 
intima  at  this  point  to  account  for  the  cell-growth.  Such  a  cell- 
proliferation  was  noted  in  certain  specimens  in  dogs  near  the  apex  of 
the  clot.  Although  no  evidence  of  cell-proliferation  could  be  de- 
tected in  the  intima  near  the  point  of  ligature,  it  is  probable  that 
some  alteration  of  the  endothelium  on  the  surface  had  taken  place 
in  the  specimens  of  four  days,  as  the  base  of  the  thrombus  was 
firmly  attached  to  the  vessel-wall.  A  slight  growth,  such  as  is  seen 
in  Fig.  3,  might  easily  be  overlooked.  In  the  four  days'  speci- 
men, there  is  a  considerable  collection  of  round  cells  in  the  centre 
of  the  thrombus,  in  greater  abundance  even  than  is  observed  in 
Fig.  2.  According  to  those  who  believe  in  the  theory  of  the  or- 
ganization of  the  thrombus,  these  would  be  regarded  as  the  first 
evidences  of  the  reparative  change.  So  far  as  can  be  determined 
in  the  present  case,  they  appear  to  be  simply  a  feature  of  the  process 
of  coagulation.  There  is  no  evidence  of  an  immigration  of  cells 
such  as  is  observed  in  Fig.  i,  although  it  is  probable  that  a  few  cells 
have  found  their  way  into  the  blood-clot  from  outside  the  walls.  Such 
an  accumulation  of  white  corpuscles  can  be  observed  in  any  clot  about 
a  bruise  in  the  vessel-wall,  and  has  no  further  significance  than  to 
serve  as  an  illustration  of  the  mode  of  coagulation  and  a  means  of 
attachment  of  the  clot  to  the  inner  coat  of  the  vessel. 

In  the  artery  tied  fifteen  days  before  death,  we  see  already  the 
beginning  of  the  second  stage  of  repair.  The  granulation  tissue 
which  surrounds  the  point  of  ligature  has  infiltrated,  and  softened 
the  tough  mass  of  elastic  fibres,  constituting  the  adventitia,  and  that 
coat  has  already  begun  to  retract,  as  has  also  the  media.  In  the 
present  case  it  is  not  possible  to  say  whether  the  external  callus  has 
been  dissected  away,  or  has  undergone  a  suppurative  softening. 
The  loosened  walls  suggest  strongly  the  probability  of  a  destructive 


Man.  95 

process,  and  it  can  readily  be  seen  how  favorable  the  conditions  for 
secondary  hemorrhage  would  be  if  a  firm  and  well-formed  external 
callus  did  not  cover  in  the  ends  of  the  vessel-walls  at  the  period 
when  they  are  freed  from  all  attachment  to  the  ligature,  and  begin  to 
retract  and  to  expand.  The  traditional  twenty-one  days  brings  us 
very  close  to  this  stage  of  the  process.  In  the  light  of  these  in- 
vestigations, the  term  "  ulceration  of  the  ligature  "  must  be  discarded 
for  some  such  phrase  as  "a  suppuration  of  the  callus;"  for  the 
ligature,  having  once  ruptured  all  but  the  band  of  elastic  fibres, 
exercises  no  further  active  pressure  upon  the  arterial  wall,  but 
encloses  the  fibres  of  the  adventitia,  as  a  ring  does  the  finger,  and 
merely  serves  to  keep  the  lumen  closed.  Further  separation  of  the 
two  portions  of  the  vessel  is  effected  by  the  action  of  the  granula- 
tion cells,  which  disintegrate  and  absorb  the  column  of  fibres  of  the 
adventitia;  thus  enabling  the  two  fragments  to  separate  slightly,  and 
leave  the  ligature  imbedded  in  a  mass  of  granulations. 

In  the  next  two  specimens,  the  subclavian  at  the  forty-sixth 
day,  and  the  femoral  at  the  fifty-fifth  day,  we  see  the  full  develop- 
ment of  the  second  stage.  The  description  of  Dr.  Lidell  of  the 
"dense  mass  of  new  connective  tissues,  so  thick  and  dense  as  to  make 
it  a  little  difficult  to  get  at  and  remove  the  specimens  without  injury," 
leaves  little  to  be  desired  as  a  description  of  the  external  callus 
which  surrounded  the  artery  on  each  side  of  the  ligature.  The  dis- 
section has  so  carved  the  specimen  as  to  represent  the  two  ends 
united  by  a  ligamentous  band,  the  condition  usually  found  at  the 
full  period  of  cicatrization;  but  the  internal  callus  has  been  left  in- 
tact, and  we  have  an  opportunity  to  examine  the  character  of  this 
structure  in  the  human  artery  at  the  end  of  the  second  month.  The 
most  striking  feature  is  the  difference  between  the  growths  in  the  two 
ends  of  the  vessel.  In  the  proximal  portion  there  is  an  elongated 
mass  of  new  formed  tissue,  filling  the  lumen  for  the  space  of  an 
inch  in  length,  a  tissue  which  is  so  far  differentiated  as  to  make  it 
probable  that  it  is  to  be  retained  in  nearly  its  present  dimensions  as 
the  permanent  cicatrix.  This  view  is  rendered  the  more  probable 
by  a  comparison  with  the  proximal  end  of  the  common  carotid  of 
four  years,  where  a  similar  elongated  mass  of  cicatricial  tissue  is  to 
be  found,  of  which  mention  will  be  made  presently.  On  the  other 
hand,  the  distal  portion  of  the  subclavian  contains  a  much  smaller 
cicatrix,  but,  what  is  more  interesting  in  this  connection,  one  which 
has  reached  already  its  full  development  into  permanent  cicatricial 
tissue,  at  a  period  when  the  other  portions  of  the  specimen  are  still 


g6  The  Ligature  of  Arteries. 

in  the  second  stage  of  development.  This  may  be  accounted  for 
by  the  nature  of  the  injury  which  left  the  distal  portion  at  the  seat 
of  ligature  comparatively  isolated  from  the  blood  current,  thus 
making  necessary  a  smaller  amount  of  cicatricial  tissue. 

In  the  femoral,  tied  in  its  continuity,  after  amputation  had  been 
performed,  we  see  not  only  the  characteristic  cicatricial  tissue  at  the 
two  ends  of  the  vessel,  but  also  a  general  narrowing  of  the  calibre 
of  the  artery  throughout  those  portions  examined,  both  by  contrac- 
tion of  the  walls  and  by  the  development  of  a  growth  in  the  inner 
wall,  a  peculiarity  characteristic  of  the  vessels  of  an  amputation 
stump. 

The  external  iliac  at  four  months  (Frontispiece,  Fig.  4),  and  the 
common  carotid  at  four  years  (Fig.  27),  are  examples  of  complete 
cicatrization.  In  both  of  these  specimens,  the  long  and  branchless 
trunk  has  been  entirely  obliterated.  In  the  iliac  artery,  a  shallow 
cul-de-sac  marks  its  origin  from  the  common  iliac.  The  depres- 
sion is  filled  with  the  typical  cicatricial  tissue.  The  remainder  of 
the  external  iliac  is  represented  by  a  bundle  of  parallel  connective 
tissue  fibres  containing  pigment  granules,  as  indicated  in  the  illustra- 
tions. In  the  common  carotid,  a  large  portion  of  that  vessel  is  also 
represented  by  a  similar  cord  of  connective  tissue,  but  a  portion  of 
the  old  vessel  still  remains  at  each  end.  In  opening  these  ends, 
however,  we  see  that  their  interior  has  been  obliterated  by  the 
formation  of  a  mass  of  cicatricial  tissue  which  fills  out  the  calibre  of 
the  vessel.  At  the  aortic  end,  the  segment  of  vessel,  thus  oblit- 
erated, was  over  an  inch  in  length,  and  the  new  tissue  extended 
nearly  to  the  origin  of  the  vessel  from  the  aortic  arch.  At  the  distal 
end,  the  cicatrix  was  short,  although  it  extended  a  little  beyond  the 
point  of  bifurcation.  In  both  of  these  large  vessels  there  was  there- 
fore, a  complete  obliteration  of  the  lumen.  In  the  iliac,  little  more 
than  a  depression  in  the  wall  of  the  main  trunk  remained  to  indicate 
its  origin. 

The  large  column  of  blood,  which  formerly  flowed  through  this 
great  vessel  was  reduced  to  a  microscopic  stream  running  through  the 
arteriole  in  the  centre  of  the  cicatrix.  The  residual  calibre,  if  such 
a  term  may  be  used,  of  the  common  carotid  was,  however,  consider- 
ably greater.  The  tissue,  filling  the  proximal  portion,  is  of  an 
erectile  character,  containing  numbers  of  large  and  tortuous  blood 
spaces;  these  do  not  appear  to  communicate  with  any  terminal  branch 
of  size,  but  form  a  tortuous  coil  of  blood-spaces,  the  equivalent  of 
a  long  narrow,  tapering  vessel  which  receives  the  powerful  stream 


Man.  97 

directed  against  it  and  distributes  it  over  an  elastic  surface  of  con- 
siderable extent,  thus  avoiding  the  excessive  strain  which  would  be 
brought  to  bear  upon  a  cicatrix  so  near  the  heart.  In  the  proximal 
end  of  the  subclavian  artery,  a  similar  mass  of  tissue  exists,  which, 
although  still  largely  mingled  with  thrombus,  and  in  an  incomplete 
stage  of  formation,  has  already  blood  spaces,  and  gives  evidence  of 
an  eventual  development  into  a  cicatrix  similar  to  that  existing  in 
the  common  carotid. 

In  large  trunks,  like  these,  the  question  naturally  arises,  have 
the  walls  been  disintegrated  and  destroyed,  or  have  they  simply 
retracted;  the  shrunken  ends  being  obliterated  by  cicatricial  tissue? 
In  the  common  carotid  detached  fragments  of  the  wall  are  seen  near 
the  distal  and  proximal  ends,  suggesting  the  occurrence  of  a  process 
which  has  terminated  in  the  destruction  of  considerable  portions  of 
the  wall  (Fig.  27),  Comparing  this  specimen  with  the  carotids  of 
the  horse  and  dog  at  four  months,  it  seems  reasonable  to  assume 
that  the  latter  show  the  beginning  of  the  process,  of  the  end  of 
which,  the  human  specimen  is  an  example,  that  we  have  an  oblitera- 
tion of  a  long  stretch  of  arterial  trunk  by  a  growth  of  tissue  in  its 
interior,  and  that  by  a  process  of  gradual  disintegration  and  atrophy 
considerable  portions  of  the  wall  may  disappear.  That  these  may, 
however,  also  remain  and  enclose  permanently  the  obliterating 
tissue  is  demonstrated  in  the  main  vessel  of  an  amputation  stump, 
soon  to  be  described;  but  there  are  no  data  on  which  to  assume  that 
such  a  condition  exists,  even  after  ligature  in  continuity,  except  in 
the  limited  extent  which  is  seen  in  the  proximal  and  distal  ends  of 
the  common  carotid  at  four  years. 

The  time  required  for  the  completion  of  the  process  of  cicatriza- 
tion in  vessels  of  the  largest  size  is  sufficiently  well  indicated  in  the 
specimens  of  the  subclavian  at  forty-six  days,  the  femoral  at  fifty- 
five  days,  and  the  external  iliac.  In  the  latter,  at  the  beginning  of 
the  fifth  month,  we  find  the  series  of  changes  thoroughly  com- 
pleted. Already  the  distal  end  of  the  subclavian  at  the  end  of  six 
weeks  has  formed  a  cicatrix  almost  as  perfect  in  its  histological 
structure  as  that  seen  in  the  external  iliac,  but  the  conditions  here, 
owing  to  the  presence  of  a  traumatic  aneurism  of  the  axillary  artery, 
may  have  favored  an  unusually  rapid  development.  It  is  safe  to 
assume  that  the  average  period  in  vessels  of  largest  size  varies  from 
three  to  four  months,  according  to  the  distance  of  collateral  branches 
from  the  point  of  ligature.  In  vessels  of  unusual  length,  like  the 
left  common  carotid,  this  period  may  be  considerably  prolonged. 
7 


^8  TJic  Ligature  of  Arteries. 

AMPUTATION. 

The  specimens  examined  were,  with  one  exception,  taken  from  the 
autopsy  table  and  the  dissecting  room.  Although  they  do  not 
cover  all  the  periods  which  it  would  have  been  desirable  to  study, 
they  follow  the  process  through  its  initial  stages  until  it  has  assumed 
a  sufficiently  definite  type  to  throw  light  upon  the  permanent  condi- 
tions which  we  find  in  an  amputation  stump,  the  result  of  dn  opera- 
tion performed  many  years  before  death.  The  arteries  are  taken 
from  the  arm,  the  axilla,  the  leg,  and  the  thigh,  and  are  of  the 
largest  size  for  those  regions.  For  the  purposes  of  comparison,  a 
specimen  of  obliterating  endarteritis  of  the  anterior  tibial  artery  is 
included  in  this  series. 

LACERATED  BRACHIAL  ARTERY. 
Two  Hours. 

A  man  was  brought  into  the  Massachusetts  General  Hospital  with 
compound  comminuted  fracture  of  the  arm.  The  brachial  artery 
had  been  ruptured,  and  protruded  from  the  surface  of  the  wounded 
tissues,  where  it  could  be  seen  pulsating,  but  not  bleeding.  The 
vessel  was  exposed  some  distance  higher  up,  and  a  ligature  was  ap- 
plied, the  portion  below  the  ligature  being  removed  for  examination. 
After  hardening  the  specimen,  longitudinal  sections  were  made. 
A  considerable  portion  of  the  specimen  was  found  to  consist  of  the 
sheath  of  the  vessel  filled  with  coagulated  blood,  the  artery  having 
retracted  some  distance. 

The  sections  show  that  the  vessel  has  been  torn  obliquely,  and 
that  the  walls  of  one  side  are  curled  up,  leaving  a  small  opening  on 
the  opposite  side  near  its  extremity  (Fig.  4).  Both  in  the  sheath 
below  the  vessel  and  opposite  the  opening  there  is  coagulated  blood, 
and  also  in  the  lumen  of  the  vessel.  This  clot  is  not  stratified.  In 
and  near  the  opening  inside  the  vessel  are  a  few  small  clumps  of 
coagulated  fibrine,  and  scattered  about  in  the  clot  are  a  few  white 
corpuscles.  The  latter  are  more  numerous  in  the  sheath  clot  (the 
"  couvercle  "  of  Petit),  near  the  end  of  the  vessel.  The  laceration 
has  evidently  torn  the  vessel  high  up  in  its  sheath,  so  that  it  retracted 
deeply  into  the  sheath,  which  was  soon  plugged  with  a  firm  coagu- 
lum.  The  injury  does  not  resemble  that  produced  by  torsion.  Hem- 
orrhage has  been  stopped,  not  by  a  twisting  of  the  fibres  of  the 
adventitia  about  the  end  of  the  vessel,  but  by  a  rapid  formation  of 


Man. 


99 


clot  in  the  sheath,  which  has  subsequently  extended   into  the  ves- 
sel. 

FEMORAL   ARTERY. 
Twenty    Hours. 

The  patient  was  brought  into  the  Massachusetts  General  Hospital, 
having  sustained  a  severe  injury,  which  required  amputation  of  the 
thigh  at  the  junction  of  the  middle  and  upper  third.  The  patient  died 
during  the  night  from  the  shock. 

The  vessel  is  an  unusually  large  one.  Immediately  above  the 
ligature  the  walls  are  thrown  into  folds  so  that  in  some  sections  they 
are  in  apposition,  and  in  others  irregularly  distended.  It  is  not 
filled  out  with  clot  close  down  to  the  ligature,  but  a  thrombus  about 
one  half  an  inch  in  length  fully  distends  the  vessel  immediately 
above,  a  slight  prolongation,  extending  up  one  side  of  the  vessel 
about  one  third  of  an  inch  further.  It  is  a  mixed  thrombus,  there 
being  large  numbers  of  white  corpuscles,  and  an  abundant  deposit 
of  layers  of  coagulated  fibrine.  The  inner  coats  are  cut  at  the  point 
of  ligature,  but  they  do  not  curve  upwards,  and  a  smooth  surface  is 
presented  to  the  base  of  the  thrombus. 

Remarks. — The  specimen  shows  a  thrombus  already  forming  in 
a  vessel,  the  interior  of  which  presents  no  irregularities  for  fibrine 
or  white  corpuscles  to  adhere  to  readily,  and  in  an  individual  whose 
circulation  was  enfeebled  by  severe  shock.  My  notes  do  not  state 
the  fact,  but  it  is  probable  that  the  usual  antiseptic  precautions  were 
observed.  Silk  thread  was  the  material  used  for  ligature.  No 
valve-like  curling  of  the  inner  walls  exists. 

TIBIAL   ARTERY. 
One  Week. 

The  vessel  was  taken  from  beneath  the  granulating  surface  of  an 
amputation  stump  about  the  middle  of  the  leg.  The  media  is 
strongly  inverted,  apparently  in  its  whole  thickness,  and,  more  or 
less  completely,  plugs  the  vessel.  The  adventitia  is  already  con- 
siderably infiltrated  with  round  cells,  a  mass  of  which  surrounds  the 
end  of  the  vessel  and  the  silk  ligature.  A  bright  red  unstratified 
thrombus  extends  about  one  and  one  half  inch  up  the  vessel.  It  is 
difficult  to  say  whether  there  has  been  an  actual  thickening  of  the 
intima.  At  one  or  two  points  this  appears  to  be  the  case,  but  these 
points  are  not  in  close  proximity  to  the  end  of , the  vessel.      There 


lOO  The  Ligature  of  Arteries. 

are  large  numbers  of  round  cells  between  the  surface  of  the  thrombus 
and  this  layer,  and  they  adhere  to  the  latter  when  the  two  are 
separated.  On  the  whole,  it  seems  probable  that  no  marked  change 
in  the  intima  has  as  yet  occurred.  At  the  stump  of  the  vessel  all 
wall-outlines  are  obliterated  by  the  contortions  of  the  media,  between 
the  folds  of  which  numerous  wandering  cells  appear  to  be  making 
their  way  from  without;  there  is  also  some  infiltration  of  the  media 
by  these  cells. 

A  second  tibial  of  the  same  date  was  removed  from  an  amputa- 
tion stump  at  about  the  middle  of  the  leg.  Longitudinal  sections 
were  made  of  the  half  of  the  specimen  nearest  the  ligature,  and 
cross  sections  were  made  of  the  other  half.  The  media  is  not 
folded  in  as  in  the  previous  case,  but  the  two  walls  lie  nearly  in 
apposition,  the  line  of  separation  being  marked  by  a  row  of  small 
round  cells  making  their  way  in  from  without,  but  not  yet  having 
accumulated  in  the  base  of  the  thrombus.  There  is  some  infil- 
tration also  of  the  broken  walls  of  the  artery  by  these  cells.  The 
thrombus  resembles  that  found  in  the  other  specimen.  The 
noticeable  feature  of  this  specimen  is  a  slight  thickening  of  the 
intima  which  consists  of  cells  with  round  and  oval  nuclei.  From 
one  or  two  points,  this  growth  projects  in  a  columnar  shaped 
mass  into  the  clot  for  a  short  distance:  this  point  is  some  distance 
from  the  ligature.  The  thickening,  however,  extends  over  the 
whole  surface  of  the  vessel  examined,  except  near  the  ligature, 
where  it  disappears.  In  one  place  there  is  a  rupture  of  the  elastic 
lamina,  and  a  growth  of  cells  appears  to  come  from  the  media  into 
the  intima. 

Remark. — The  appearances  noted  in  the  vessel  of  an  amputation 
stump  at  this  period  suggest  the  beginning  of  an  obliteration  of 
the  lumen  of  the  remaining  portion  of  the  artery,  rather  than  of  a 
healing  process  limited  to  the  end  of  the  vessel. 

AXILLARY  ARTERY. 
One  Week. 

The  specimen  was  obtained  from  a  hospital  patient  who  died 
after  amputation  for  gangrene  following  a  compound  comminuted 
fracture.  The  axilla  was  found  in  a  putrid  state  at  the  autopsy. 
One  large  vessel  was  found  exposed,  but  plugged  with  a  clot  pro- 
truding from  its  end.  Another  larger  vessel,  either  the  lower  portion 
of  the  axillary  or  the  beginning  of  the  brachial,  was  removed  for 


Man.  I  o  I 

examination.  The  end  of  the  vessel  was  enclosed  in  the  granulation 
tissue,  the  ligature  having  come  away. 

Longitudinal  sections  show  a  small  clot  of  pale  color,  adherent 
to  the  end  of  the  lumen.  Under  the  microscope  this  is  seen  rest- 
ing upon  a  growth  of  new  tissue  consisting  chiefly  of  spindle-shaped 
cells,  and  also  of  round  cells.  It  has  the  appearance  of  granula- 
tions, which  are  infiltrating  the  thrombus,  growing  chiefly  in  colum- 
nar masses.  The  walls  of  the  vessel  have  separated  slightly,  and 
there  is  an  extension  of  the  growth  of  granulation  cells  from  the 
outside  into  the  interior.  There  is  an  excellent  opportunity  to 
study  the  intima  in  this  specimen,  as  the  clot  is  small,  and  the  internal 
tunic  possesses  quite  a  deep  thick  layer  of  longitudinal  fibres,  as  is 
usually  the  case  in  large  arterial  trunks.  Curiously  enough,  the 
intima  is  the  thickest  at  the  point  most  remote  from  the  ligature. 
Here  are  seen  the  longitudinal  connective  tissue  fibres,  covered  with 
a  single  layer  of  endothelial  cells,  and  interspersed  with  a  few  cells, 
having  round  and  oval  nuclei.  Farther  down,  this  coat  gradually 
diminishes  in  thickness  until  but  one  or  two  fibres  intervene  between 
the  endothelium  and  the  lamina:  from  this  point  it  becomes  slightly 
thicker,  and  there  are  a  few  more  nuclei  to  be  seen.  In  the  im- 
mediate neighborhood  of  the  ligature  it  widens  out  considerably, 
and  becomes  lost  in  the  new  growth.  The  endothelium  appears  to 
undergo  no  change,  but  to  be  continued  out  on  the  surface  of  the 
columnar  granulations  of  this  new  tissue. 

Remarks. — On  account  of  the  acute  septic  inflammation,  the  liga- 
ture has  separated,  and  the  walls  of  the  vessel  have  opened  suffi- 
ciently to  admit  a  growth  of  granulation  tissue  which  has  permeated 
the  base  of  the  clot.  This  new  tissue  or  "  plastic  clot"  appears  to 
be  directly  continuous  with  the  intima.  That  coat,  however,  proba- 
bly participates  in  the  growth  only  to  a  limited  extent,  the  main 
portion  being  derived  from  the  granulation  tissue,  which  has  grown 
in  from  without.  The  changes  noted  in  the  intima  do  not  indicate, 
as  yet,  any  material  activity  of  that  tunic.  The  narrowing  of  the 
coat  above  described  is  evidently  an  anatomical  condition.  The 
slight  thickening  noted  lower  down  may  indicate  the  beginning  of  a 
pathological  thickening.  The  small  size  of  the  thrombus  is  due, 
probably,  to  the  close  proximity  of  a  branch,  (the  one  seen  pro- 
truding from  the  granulations),  its  friable  condition  being  caused 
by  the  septic  inflammation.  The  end  of  the  vessel  is,  however,  for 
the  time  being,  held  together  by  the  granulation  tissue,  which  has 
found  its  way  in  at  an  earlier  period  than  usual. 


I02  The  Ligature  of  Arteries. 

TIBIAL   ARTERY. 
Three  Weeks. 

J.  L.  was  brought  into  the  Massachusetts  General  Hospital  with 
a  compound  comminuted  fracture  of  both  legs.  Double  amputation 
was  performed,  the  patient  dying  three  weeks  later  of  pyemia.  Am- 
putation had  been  performed  on  one  side,  about  the  middle  of  the 
leg,  and  on  the  other,  at  the  end  of  the  upper  third.  The  anterior 
tibial,  tied  at  about  its  middle  point,  presented  the  following  appear- 
ance. 

The  end  of  the  vessel  is  surrounded  with  granulation  tissue,  in 
which  the  silk  ligature  can  still  be  seen  imbedded.  Longitudinal 
sections  show  that  the  media  has  been  curled  in  and  has  blocked  up 
the  end  of  the  vessel,  so  that  only  a  small  number  of  granulation 
cells  have  found  access  to  the  interior.  The  cavity  of  the  vessel  is 
filled  with  unstratified  clot,  into  which  a  growth  of  granulations  is 
taking  place,  partly  filling  the  vessel  for  about  one  quarter  of  an 
inch  from  its  end.  It  seems  to  spring  from  the  point  of  ligature, 
but  is  adherent  at  one  or  two  points  to  the  intima,  in  which  coat  a 
striking  change  is  apparent.  This  change  consists  in  a  considerable 
thickening  of  this  tunic,  which  greatly  narrows  the  already  contracted 
vessel.  The  tissue  of  which  it  is  composed  consists  of  a  more  or 
less  transparent  intercellular  substance,  in  which  are  imbedded  long 
spindle-shaped  cells  with  staff-shaped  nuclei  (Fig.  5).  Near  the 
surface  the  nuclei  are  shorter  and  more  irregular  in  shape  and  ap- 
pearance. Here  and  there  clusters  of  leucocytes  are  found  attached 
to  the  surface.  The  spindle-shape  is  confirmed  by  cross  sections, 
and  sections,  taken  so  as  to  see  the  cells  in  face,  as  well  as  in  profile. 
No  new  vessels  are  noticed  in  this  layer,  nor  is  any  distinct  commu- 
nication between  it  and  the  middle  coat  made  out.  The  growth 
extends  beyond  that  part  of  the  vessel  removed  for  examination, 
and  down  to  the  point  of  ligature,  being  reflected  upon  the  curled-in 
edges  of  the  media.  It  is  in  communication  with  the  granulations 
in  the  thrombus,  the  cells  of  which  are  similar. 

Remarks. — The  conditions  observed  here  are  those  which  proba- 
bly prevail  in  vessels  of  amputation  stumps,  a  preliminary  stage  of 
the  obliterating  endarteritis,  by  which  the  vessel  is  reduced  to  a  cord 
containing  a  greatly  diminished  lumen,  or  one  or  two  small  lumina, 
in  order  to  adapt  it  to  the  greatly  diminished  blood  supply  to  the 
part.  The  growth  seen  in  the  intima  probably  comes  from  its  deeper 
layers,    from    some    portions    of    the    media,   and    from    the    tissue 


1 


Man.  1 03 

accumulating  at  the  point  of  ligature.  It  appears,  however,  to  be 
chiefly  derived  from  the  deep  layer  of  the  intima.  It  is  probable 
that  this  thickening  could  have  been  traced  to  the  origin  of  the  tibial, 
and  possibly  into  the  popliteal  artery.  The  shape  of  the  nuclei  sug- 
gests a  strong  resemblance  to  the  muscular  cells,  although  at  this 
stage  of  development,  it  would  be  impossible  to  express  an  opinion 
as  to  their  true  nature. 

TIBIAL   ARTERY. 

Three  Weeks. 

The  anterior  tibial  artery,  at  about  the  junction  of  the  middle 
and  upper  third  was  found  protruding  from  the  granulations,  in  the 
case  mentioned  above,  the  walls  being  separated,  and  a  large  clot 
plugging  the  expanded  mouth  of  the  vessel. 

On  dividing  the  vessel  longitudinally  the  clot  is  found  to  be  quite 
short,  terminating  at  the  level  of  a  branch  of  considerable  size;  the 
surface  which  it  presents  to  the  lumen  is  slightly  concave  (Fig.  14). 
It  is  firmly  attached  to  the  walls  of  the  vessel,  which  at  this  point  are 
undergoing  infiltration  with  wandering  cells,  many  of  which  have 
penetrated  the  thrombus  through  the  media.  It  is  also  securely 
attached  to  a  growth  of  the  intima,  which  is  to  be  found  on  one  side 
of  the  vessel  only,  that  opposite  to  the  branch.  Starting  from  a 
point  somewhat  below  the  level  of  the  upper  end  of  the  thrombus,  it 
can  be  traced  to  the  end  of  the  specimen.  At  a  point  a  little  above 
that  represented  in  the  drawing  it  has  widened,  to  such  an  extent, 
as  nearly  to  close  the  lumen  of  the  vessel.  There  is  also  a  slight 
thickening  of  the  intima  on  the  other  side,  running  down  into  the 
branch.  The  tissue,  of  which  this  consists,  is  of  a  hyaline,  mucous 
character,  and  contains  spindle,  oval,  and  round  cells:  a  number  of 
young  capillary  vessels  may  be  seen  ramifying  in  it  (Fig.  15).  At 
certain  points  there  are  clusters  of  round  cells,  and  at  corresponding 
points  in  the  adventitia  there  may  also  be  seen  large  clusters  of  the 
same  cells,  making  their  way  into  and  through  the  media.  The 
upper  layer  of  the  intima,  consisting  of  double  laminze,  with  interven- 
ing cells,  may  be  seen  lying  below  this  thickening  of  the  intima. 
The  cells,  lying  between  the  laminae,  are  arranged  longitudinally, 
and  have  staff-shaped  nuclei.  This  anatomical  arrangement  is  pecu- 
liar to  the  tibial  artery.  At  one  or  two  points  on  the  surface  of  the 
new  tissue  is  an  appearance  of  a  formation  of  a  new  elastic  lamina. 
The  absence  at  certain  points  of  one  of  the  deep  lamina,  and  the 
evidence  seen  at  others,  of  cell-growth  taking  place  between  them. 


I04  TiLe  Ligature  of  Arteries. 

as  studied  in  cross  sections,  suggest  strongly  the  displacement  of  one 
of  these  membranes,  as  an  explanation  of  this  phenomenon. 

Remarks. — We  have  here  a  condition  preliminary  to  secondary 
hemorrhage,  and  an  illustration  of  nature's  effort  to  prevent  it.  The 
softening  effects  of  the  suppurating  granulations  have  cast  off  the 
ligature,  and  have  not  provided  a  substitute  for  it:  the  walls  have 
consequently  expanded,  and  the  thrombus  is  protruded.  The  same 
intense  inflammatory  action  has,  however,  infiltrated  the  walls  to 
such  an  extent  as  to  hold  the  thrombus  in  contact  with  the  vessel  so 
long  as  it  shall  hold  itself  together.  In  the  meantime,  the  artery  is 
rapidly  liecoming  diminished  in  calibre  in  its  whole  length.  The 
cells  seen  between  the  lamina?  of  the  tibial  artery  are  usually  re- 
garded as  connective  tissue  cells,  but  they  have  much  more  the  ap- 
pearance of  a  bundle  of  longitudinal  muscular  fibres.  The  question 
of  a  new  formation  of  an  elastic  lamina  has  been  frequently  raised. 
With  this  exception,  no  appearances  suggesting  such  a  growth  have 
been  observed,  and  in  this  case  the  formation  of  new  elastic  mem- 
brane is  quite  doubtful.  The  appearances  of  the  clot  and  its  shape 
and  relation  to  the  walls  are  similar  to  those  described  by  Kocher 
as  seen  after  acupressure. 

POSTERIOR   TIBIAL   ARTERY. 
Three  Weeks. 

One  of  the  posterior  tibial  arteries  in  the  above  case  was  preserved 
for  examination.  The  coats  of  the  vessel  were  folded  in  at  the  point 
of  ligature,  and  the  convolutions  were  glued  together  by  a  growth  of 
cells.  There  were  a  number  of  immigrant  cells  at  this  end  of  the 
vessel.     There  was  a  slight  thickening  of  the  intima  on  one  side. 

FEMORAL   ARTERY. 

Fifteen  Years. 

The  specimen  was  taken  from  the  thigh  of  a  dissecting  room 
subject.  Little  was  known  of  the  man's  history:  he  had  been  in  the 
almshouse  for  fifteen  years,  having  lost  the  leg  from  an  injury  re- 
ceived at  sea.  Amputation  had  been  performed  through  the  junc- 
tion of  the  middle  and  lower  thirds.  On  dissection,  a  round  and 
firm  cord-like  mass  was  found  running  from  the  origin  of  the  pro- 
funda to  the  cicatricial  tissue  of  the  stump,  gradually  diminishing 
in  size  towards  its  terminus.  The  femoral,  above  this  point,  was 
much  contracted.     Both  longitudinal  and  cross  sections  were  made 

/ 


t 


Man.  105 

at  various  points.  Tliese  showed  that,  although  apparently  a  cord, 
the  walls  of  the  vessel  still  remained,  more  or  less  perfectly  pre- 
served, and  that  the  lumen  had  been  greatly  diminished  in  calibre 
by  an  "  obliterating  endarteritis." 

In  longitudinal  sections  taken  near  the  origin  of  a  larger  branch, 
presumably  the  profunda,  the  vessel  is  found  filled  with  a  new 
growth,  which  extends  some  distance  above  the  origin  of  the  latter 
vessel  on  the  opposite  side.  Below  this  point  it  apparently  fills  the 
greater  portion  of  the  vessel,  but  in  the  centre  a  tortuous  lumen  can 
be  traced.  Owing  to  cadaveric  changes,  the  tissues  do  not  stain 
easily,  but  a  careful  study  of  the  different  forms  of  tissue  found 
shows  them  to  be  of  such  a  character  as  to  constitute  a  tolerably 
complete  new  wall  to  the  new  lumen  (Fig.  2,Z)-  No  endothelium 
can  be  made  out,  but  next  to  the  lumen  is  a  dense  glistening  mass  of 
fibrous-like  tissue,  in  which  a  few  staff-shaped  nuclei  have  taken  the 
staining.  These  cells  are  seen  in  greater  abundance  farther  out, 
and  run  both  circularly  and  longitudinally.  The  longitudinal  mus- 
cular cells  are  very  abundant  in  some  sections.  There  is  also  a 
loose  areolar  tissue  between  them  and  the  old  muscular  coat.  "^I'his 
coat  has  undergone  extensive  calcification.  In  cross  sections,  taken 
a  little  lower  down,  the  vessel  appears  to  have  a  larger  lumen. 
There  seems  to  be,  just  inside  of  the  old  muscular  coat,  a  musculo- 
elastic  layer;  still  further  in,  some  of  the  longitudinal  muscular  cells 
are  now  seen  in  cross  section,  and  finally,  next  to  the  lumen, 
fibrous  tissue  exists  in  which  a  few  cells  can  be  found.  The  lumen 
is,  in  most  sections,  divided  into  two  channels  by  a  band  of  fibres 
running  across  the  vessel.  In  longitudinal  sections,  taken  at  the 
terminus  of  the  cord,  traces  only  of  a  lumen  and  vessel -walls  are 
found.  The  lumen  has  grown  so  small  as  finally  to  be  little  larger 
than  an  arteriole,  and  a  mass  of  anastomosing  capillaries  and  arte- 
rioles, surrounding  this,  indicates  the  system  of  vessels,  in  which 
the  artery  finally  loses  itself. 

Remarks. — We  have  here  a  condition  closely  resembling  what  is 
usually  described  as  "  endarteritis  obliterans."  It  would,  however, 
be  more  appropriately  termed  "compensatory  endarteritis,"  al- 
though not  corresponding  closely  with  the  changes  observed  by 
Thoma  in  that  process.  We  see  here  an  adaptation  to  the  very 
greatly  diminished  blood  supply  of  the  limb.  We  find  no  distinct 
cicatrix  at  the  point  of  ligature,  but,  instead,  a  gradual  diminution 
of  its  calibre  in  the  entire  length  of  the  vessel,  and  a  partial  oblitera- 
tion below  the  profunda.     The  section  shows  apparently  a  vessel  of 


io6  The  Ligature  of  Arteries. 

large  size  terminating  in  the  cicatrix  of  the  stump,  but  microscopical 
examination  shows  a  diminution  of  the  calibre  of  the  main  trunk  to 
the  size  of  many  of  its  branches.  The  condition  of  the  new  circula- 
tion in  the  stump  would  be  best  demonstrated  by  a  corrosion  prepa- 
ration which  would  represent  the  nevv  cavities  of  the  vessels  without 
their  covering.  This  would  show  that  the  main  trunk  soon  breaks 
up  into  a  number  of  branches,  of  nearly  equal  size,  which  distribute 
the  blood  to  the  different  portions  of  the  stump. 

ENDARTERITIS   OBLITERANS   TIBLE:. 

W.  E.  H.,  50  years  old,  entered  the  Hospital,  March,  1884,  with 
gangrene  of  the  great  toe  and  a  portion  of  the  same  foot.  He  had 
injured  it  two  months  before  in  very  cold  weather.  The  leg  was 
amputated  a  few  days  later  at  the  point  of  election.  The  patient 
recovered  from  the  operation,  and  the  wound  healed  well  during  the 
first  two  weeks,  but  he  died  on  the  seventeenth  day,  after  three  days 
of  severe  illness.  The  following  is  a  summary  of  the  autopsy: 
"Calcification  of  the  tibial  arteries;  chronic  endarteritis  with  ob- 
literation of  the  coeliac  axis;  obliteration  of  splenic  artery;  traumatic 
thrombosis  of  femoral  vein;  embolism  of  pulmonary  artery;  throm- 
bosis from  stagnation  in  splenic  vein;  continued  thrombosis  of  portal 
vein;  marantic  thrombosis  of  spermatic  and  renal  veins;  anemic 
necrosis  of  spleen;  anemic  necrosis  of  liver."  A  portion  of  the 
anterior  tibial  artery  was  preserved  for  microscopical  examination. 
The  lime  salts  having  been  dissolved  out,  longitudinal  and  trans- 
verse sections  were  made. 

In  longitudinal  sections  the  interior  appears  to  be  filled  with  a 
hyaline,  homogeneous,  slightly  fibrillated,  intercellular  substance 
containing  round  and  spindle-shaped  cells,  the  latter  having  staff- 
shaped  nuclei  and  closely  resembling  muscular  cells.  Vessels  of 
considerable  size  run  lengthwise,  in  a  more  or  less  tortuous  course: 
in  some  sections  there  are  numerous  coils  of  vessels,  giving  the  tissue 
a  cavernous  appearance.  In  transverse  sections  the  new  tissue  is 
found  to  be  pierced  by  two  vessels  of  considerable  size,  the  walls 
of  which  contain,  not  only  a  delicate  endothelium  and  several  rows 
of  muscular  cells,  Init  also,  between  these  layers,  a  well  defined  line 
which  might  pass  for  an  elastic  lamina.  These  vessels  are  supported 
by  a  connective  tissue  which  fills  out  the  lumen,  except  at  its  peri- 
phery, where  there  appears  to  be  a  layer  of  hyaline  tissue  containing 
but  few  cells,  and  nearly  encircling  the  interior  of  the  vessel.  There 
are  numerous  pigment  granules  scattered  here  and  there  in  the  new 
tissue.     (Fig.  35.) 


Man.  107 

In  the  media  of  the  tibial  artery  are  numerous  calcareous  patches, 
which  occupy  the  greater  portion  of  this  layer.  This  coat  is  thrown 
into  both  longitudinal  and  circular  folds,  at  times  bulging  deeply  into 
the  obliterating  tissue.  The  lamina  is  frequently  wanting,  and  a 
proliferating  mass  appears  to  grow  into  this  tissue.  A  portion  of 
the  muscular  wall  is  intact,  but  in  many  places,  granulation  cells  are 
seen  in  great  numbers,  and  numerous  capillary  vessels,  and  even 
arterioles.     There  is  no  appreciable  change  in  the  adventitia. 

Remarks. — The  appearances  described  strongly  suggest  an  active 
participation  of  the  middle  coat  in  the  obliterating  process.  The  cal- 
cification, possibly  the  original  disease,  is  situated  in  this  coat.  Nu- 
merous cells  strongly  resembling  muscular  cells  are  seen  in  the  new 
tissue,  and  the  new  large  vessels  are  abundantly  supplied  with  muscu- 
lar fibre.  In  fact,  a  new  tibial  channel  has  been  constructed.  There 
is  a  striking  resemblance  in  this  process  to  that  seen  in  the  large 
arteries  of  stumps,  and  the  similarity  of  the  two  conditions  suggests 
the  query:  may  not  the  obliteration  in  the  present  case  be  an  adapta- 
tion to,  rather  than  the  cause  of,  the  diminished  blood  supply  to 
the  extremity  ? 

In  the  first  specimen  of  this  series  we  have  an  example  of  nature's 
method  of  arresting  hemorrhage.  The  injury  was  one  of  those  severe 
lacerations  for  which  amputation  was  necessary.  The  vessel  was 
seen  protruding  from  the  tissue  as  a  solid  cord-like  mass,  an  inch  or 
more  in  length,  moving  visibly  with  each  pulsation.  The  vessel  had 
retracted  within  its  sheath  for  a  considerable  distance,  much  greater 
than  is  shown  in  the  drawing  (Fig.  4),  and  had  been  plugged  by  an 
internal,  as  well  as  b)'  an  external  thrombus.  Other  sections  showed 
a  slight  fissure  on  the  side  opposite  to  the  opening  seen  in  the  draw- 
ing, but  the  one  represented  in  the  figure  is  the  only  one  of  any  size, 
as  indicated  also  by  the  extravasation  of  blood  between  the  vessel 
and  its  sheath  in  the  immediate  neighborhood. 

An  interesting  feature  is  the  absence  of  the  conditions  which  one 
would  expect  to  find  in  torsion,  due  possibly  to  the  fact  that  the 
walls  have  been  torn  unequally,  and  that  the  opening  appears  upon 
one  side,  rather  than  at  the  end  of  the  vessel.  There  is  no  curling 
in  of  the  inner  coats,  and  the  adventitia  is  not  twisted  about  the  end 
of  the  vessel.  Hemorrhage  appears  to  have  been  arrested  by  a  co- 
agulation of  blood  within  the  sheath,  followed  by  a  formation  of  a 
thrombus  inside  of  the  vessel. 

In  this  case  there  is  no  stratification  of  the  thrombus,  a  peculiarity 


io8  The  Ligature  of  Arteries. 

which  appears  to  exist  only  when  the  formation  of  the  thrombus  has 
taken  place  slowly.  Such  is  the  case  in  the  next  specimen,  where, 
at  the  end  of  twenty  hours,  a  comparatively  small  thrombus  has  been 
developed.  This  may  have  been  due  to  the  presence  of  a  branch, 
but  it  is  probable  that  antiseptic  precautions  had  an  influence  upon 
its  size.  This  condition  of  the  clot  was  also  seen  chiefly  in  large 
vessels,  in  which  it  was  universal  to  a  greater  or  less  degree;  it  was 
also  noticed  in  some  of  the  experiments  on  the  arteries  of  dogs.  It 
is  interesting  to  note  here,  that,  in  the  axillary  artery,  the  thrombus 
was  exceedingly  small,  in  spite  of  an  intensely  septic  wound,  show- 
ing that  such  conditions  do  not  necessarily  produce  an  extensive 
thrombosis  in  the  human  subject. 

In  the  axillary  artery  the  end  of  the  vessel  had  already  begun  to 
open  at  the  end  of  a  week  sufiiciently  to  admit  a  column  of  granula- 
tion cells,  which  were  beginning  to  invade  the  lumen.  In  the  same 
wound,  a  vessel  had  opened  to  such  an  extent  that  the  thrombus  was 
exposed  on  the  surface,  the  destructive  process  having  prevented 
the  granulations  from  filling  the  gap. 

The  most  important  observation  made  on  the  series  of  vessels 
included  within  the  period  of  the  first  three  weeks,  was  the  growth 
of  tissue  on  the  inner  wall  of  the  vessels.  The  first  indications  of 
such  a  growth  were  observed  at  the  end  of  the  first  week,  and  at  the 
third  week  it  had  already  become  a  layer  of  sufficient  thickness  to 
diminish  perceptibly  the  lumen. 

In  Fig.  5  we  see  the  character  of  this  growth,  which  consists 
of  spindle-shaped  cells  with  elongated  nuclei.  In  the  tibial  arteries, 
in  which  this  growth  was  studied,  there  exist  two  laminae,  between 
which  similar  cells  are  seen,  and  the  conclusions  drawn  from  the 
examinations  of  both  longitudinal  and  cross  sections,  point  to  a 
growth,  not  only  from  the  inner,  but  also  from  the  middle  coat. 
This  new  tissue  was  found,  not  only  on  the  inner  surface  of  the 
vessel,  but  also  projecting  in  granulation-like  masses  into  the  throm- 
bus, and  it  was  evident  that  the  process,  known  as  obliterating  end- 
arteritis, was  to  be  seen  here  in  its  earliest  stages. 

In  most  of  the  tibial  vessels  examined,  the  middle  coat  had  been 
turned  upwards  into  the  lumen  at  the  moment  of  ligature,  and  had 
effectually  blocked  up  the  opening.  Such  a  valve-like  closure  was 
not  seen  in  any  of  the  other  vessels  examined,  and  it  seemed  proba- 
ble that  this  incurvation  of  the  inner  walls  was  due  to  the  peculiar 
character  of  the  walls  of  this  artery.  In  most,  of  the  vessels  ex- 
amined, whether  tied  in  continuity  or  in  the  amputation  stump,  in 


Man.  109 

man,  or  in  animals,  there  was  no  valve-like  folding-in  of  the  walls, 
except  in  the  tibial  artery;  in  all  other  cases  such  a  condition  as  is 
represented  in  Plate  I.  prevailed. 

The  condition  of  the  tibial  artery  at  three  weeks,  with  a  protrud- 
ing thrombus  (Plate  V.)  is  of  unusual  interest  as  illustrating,  not  only 
the  mode  of  closure  of  one  of  these  vessels,  but  also  nature's  mode 
of  dealing  with  an  emergency.  Owing  to  the  degree  of  suppura- 
tion, the  retracting  walls  have  not  been  sealed  by  the  usual  growth 
of  granulation  tissue,  and  have  expanded,  allowing  the  thrombus  to 
protrude  slightly.  The  walls  on  either  side,  have,  however,  become 
infiltrated  with  wandering  cells,  which  have  penetrated  the  thrombus 
in  large  numbers,  thus  attaching  the  thrombus  firmly  to  the  vessel- 
wall,  and  enabling  it  to  resist  the  expulsive  efforts  of  the  blood- 
column.  The  blood-stream  has,  however,  been  considerably  dimin- 
ished in  size  and  force,  by  the  narrowing  of  the  lumen,  which  has 
resulted  from  an  active  growth  from  the  vessel-walls,  and  this  growth, 
has,  curiously  enough,  been  most  vigorous  a  short  distance  above 
the  point  of  bifurcation  of  a  branch.  There  the  lumen  had  already 
become  so  narrow  that  it  is  highly  probable  that,  had  the  thrombus 
become  softened  by  a  puriform  infiltration,  hemorrhage  might  have 
been  prevented  by  closure  at  this  point.  If,  on  the  other  hand, 
healing  had  taken  place,  the  artery  would  have  probably  narrowed  at 
the  same  point  into  a  fine  arteriole,  which  would  have  communicated 
with  the  capillary  system  of  the  stump.  The  extra  development 
at  the  point  mentioned,  the  upper  portion  of  Fig.  14,  seems  to  be  in 
part  due  to  a  wandering  of  cells  through  the  walls.  This  may,  how- 
ever, have  been  an  accidental  feature  of  the  severe  inflammation 
which  simply  stimulated  a  more  vigorous  growth  from  the  vessel-walls 
at  a  point  most  favorable  for  it.  This  growth  has  as  yet  taken  on 
no  typical  development,  but  is  a  myxomatous  tissue  in  a  state  of 
active  formation.  The  relations  of  the  growth  to  the  direction  of 
the  blood-stream,  and  the  influence  exerted  upon  it  by  the  presence 
of  a  V:)ranch,  are  also  well  shown. 

In  laying  open  the  thigh,  through  the  lower  third  of  which  ampu- 
tation had  been  performed  many  years  before,  the  femoral  artery 
could  be  traced  from  its  origin  to  the  cicatrix  at  the  end  of  the  stump. 
At  Poupart's  ligament  its  calibre  had  already  greatly  diminished,  and, 
on  opening  the  vessel  from  above  downwards,  the  old  lumen  was 
seen  to  be  obliterated  a  short  distance  below  the  profunda.  Below  this 
point  the  condition  closely  resembled  that  seen  in  an  obliterating 
endarteritis.     Externally  the  old  vessel  appeared  to  exist  as  before, 


no  TJic  Ligature  of  Arteries. 

though  smaller  in  size.  Internally,  there  was,  however,  a  newly 
formed  mass  of  tissue,  through  which  a  small  stream  flowed  in  two  or 
more  channels.  (Fig.  33.) 

The  specimen  taken  from  a  case  of  true  endarteritis  obliterans 
shows  more  satisfactorily  the  histological  details.  (Fig  53.)  As  the 
amputation  specimen  was  taken  from  a  dissecting-room  subject, 
the  cadaveric  change  has  injured  the  tissues  sufficiently  to  interfere 
with  a  staining  suitable  for  study  with  high  powers.  It  is  worthy  of 
note  that  we  have  here  a  trunk  obliterated  through  a  large  portion 
of  its  extent,  without  an  absorption  of  its  walls,  such  as  was  assumed 
to  have  taken  place  in  the  ligature  of  the  common  carotid  in  its  con- 
tinuity. The  condition  of  the  blood  supply  to  the  neighboring  parts 
was  not,  however,  the  same  in  the  two  cases.  In  the  ligature  in 
continuity  the  main  trunk  had  been  relieved  from  further  duty  by 
an  abundant  collateral  circulation,  but,  in  the  amputation  stump,  the 
artery  beyond  the  profunda  had  been  reduced  in  size,  but  not  obliter- 
ated, as  the  blood  supply  to  the  part  had  been  permanently  dimin- 
ished, and  the  need  of  a  powerful  collateral  supply  did  not  exist. 

If  we  may  judge  from  the  specimens  examined,  it  is  evident 
that  the  course  of  the  process  of  repair  of  arteries  in  amputation 
stumps  is  quite  different  from  that  occurring  after  ligature  in  con- 
tinuity. In  the  latter  case  we  have  a  distinct  cicatrix  developed  at 
the  end  of  a  vascular  cul-de-sac;  in  the  former,  however,  no  cica- 
trix, as  such,  exists.  We  see  the  main  trunk,  soon  after  entering  the 
limb,  breaking  up  into  a  spray  of  smaller  vessels,  which  distribute 
themselves  more  or  less  equally  to  the  different  portions  of  the 
stump. 


I 
I 


CHAPTER  IV. 

THE    CLOSURE    OF    THE  FOETAL    VESSELS. 
The  Ductus  Artp:riosus. 

The  obliteration  of  two  important  blood-vessels  at  the  time  of 
birth  affords  examples  of  nature's  method  of  forming  a  cicatrix  when 
unaided  by  surgical  art.  The  analogy  between  the  closure  of  the 
ductus  arteriosus  and  the  obliteration  of  a  vessel,  after  ligature  in 
continuity,  is  one  that  suggests  itself  even  on  superficial  examination. 
A  large  blood  channel  is  suddenly  obstructed  and  becomes  perma- 
nently closed  at  the  point  of  obstruction,  and  a  collateral  circulation 
is  immediately  established.  Here  we  have  an  opportunity  to  ex- 
amine the  nature  of  the  cicatrix  in  the  aortic  wall,  a  cicatrix  the 
conditions  of  which  differ  but  slightly  from  those  studied,  for  in- 
stance, in  the  common  iliac,  at  the  point  of  origin  of  the  external 
iliac  artery  obliterated  by  ligature.  In  the  hypogastric  and  umbilical 
arteries  a  large  portion  of  an  arterial  trunk  is  removed,  cicatrization 
taking  place  in  the  remaining  portion;  conditions  closely  resembling 
those  existing  in  the  stump  of  an  amputated  limb.  It  remains  to 
be  seen  then  what  analogies  exist  between  the  healing  of  these  foetal 
structures  and  the  two  modes  of  repair  after  ligature  which  have 
just  been  studied. 

A  review  of  the  literature  bearing  upon  the  anatomical  structure 
of  the  ductus  arteriosus  shows  considerable  diversity  of  opinion 
upon  the  nature  of  its  histological  elements;  and  existing  descrip- 
tions of  the  series  of  changes  which  take  place  during  the  process  of 
obliteration,  are  not  satisfactory.  There  is  little  also  to  be  found, 
bearing  upon  the  changes  in  the  hypogastric  artery,  suitable  for  our 
present  purpose. 

The  following  selections  have  been  made,  as  they  present  some 
points  of  interest  in  this  connection.  For  the  literature  on  this  sub- 
ject the  reader  is  referred,  however,  to  the  bibliography. 

Thoma  gives  the  following  description  of  the  anatomy  and 
changes  in  the  ductus  arteriosus.  In  the  intima  he  finds  a  tissue 
composed  of  elastic  fibres  interspersed  with  muscular  cells,  resting 
upon  the  elastic  lamina,  and  covered  by  endothelium,  a  peculiar  ar_ 


112  TJie  Ligature  of  Arteries. 

rangement  which  also  obtains  in  the  puhiionary  artery  near  the  open- 
ing, as  well  as  in  the  aorta  at  the  same  point.  This  arrangement  is 
similar  to  that  already  described  at  the  points  of  bifurcation  of  the 
large  vessels  from  the  aorta.  The  elastic  lamina  is  continuous  with 
that  seen  in  the  pulmonary  artery,  and  runs  nearly  to  the  aortic  end 
where  it  is  lost.  The  media  differs  materially  from  that  of  the  ad- 
jacent large  vessels.  The  strong  elastic  membranes  are  replaced  by 
thin  narrow  membranes  and  elastic  fibres.  There  are  large  numbers 
of  muscular  cells,  and  the  arrangement  is  longitudinal  rather  than 
circular.  A  contraction  of  these  fibres  near  the  centre  of  the  duct 
causes  that  portion  of  the  lumen  to  be  narrower  than  elsewhere. 
At  the  point  where  the  elastic  lamina  is  wanting,  the  elements  of  the 
two  coats  of  the  ductus  and  the  aorta  become  mingled  with  one 
another.  The  muscular  elastic  layer  of  the  intima  of  the  aorta  is 
most  pronounced  just  below  the  opening  of  the  ductus,  and  is  due  to 
the  fact  that  the  fibres  of  this  tube  spread  out  chiefly  downwards 
through  the  media  of  the  aorta,  some  losing  themselves  in  that  layer, 
others  penetrating  the  intima  aortae.  The  elastic  lamina  of  the  aorta, 
just  at  this  point,  is  not  a  continuous  membrane,  and  the  elements 
of  the  two  coats  intercross  somewhat.  This  thickening  of  the  intima 
disappears  a  few  millimetres  below  the  opening  of  the  ductus.  A 
few  days  after  birth  the  endothelium  of  the  intima  of  the  ductus  is 
thrown  into  thick  folds,  by  the  contraction  in  part  of  its  own  muscu- 
lar cells,  and  in  part  of  those  of  the  media.  They  appear  also  to 
be  somewhat  swollen,  and  help,  with  the  muscular  contraction  of 
the  media,  to  close  the  lumen  of  the  vessel.  The  intima  of  the 
aorta  also  undergoes  a  change  which  extends  from  the  opening  of 
the  ductus  throughout  the  whole  length  of  the  aorta.  It  consists 
in  the  development  of  a  hyaline  connective  tissue  just  beneath  the 
endothelium.  Its  cells  are  quite  different  from  the  muscular  cells 
already  described,  and  there  are  no  elastic  fibres  in  it. 

As  seen  at  the  fifth  year  the  muscular  fibres  of  the  ductus  have 
atrophied  and  disappeared,  and  the  opening  has  been  closed  by  a 
growth  of  connective  tissue.  In  specimens  examined,  ranging  from 
twelve  to  twenty-four  years  after  birth,  remains  of  the  fibres  of  the 
ductus  are  still  found  in  the  aorta,  some  looking  like  cicatricial  tis- 
sue, others  having  undergone  the  characteristic  hyaline  degenera- 
tion. It  is  worthy  of  mention  that  Thoma  states  that  the  muscular 
tissue  and  the  connective  tissue  of  the  intima  of  the  aorta  closely 
resemble  one  another,  and  sometimes  cannot  be  distinguished  from 
one  another. 


TJic  Closure  of  the  Fecial  Vessels.  113 

In  the  umbilical  (hypogastric)  artery, according  to  the  same  author, 
the  elastic  lamina  is  continued  only  through  the  pelvic  portion  of 
that  vessel:  from  that  point  to  the  navel  the  lining  membrane  con- 
sists solely  of  endothelium.  At  the  time  of  birth  there  is  a  contrac- 
tion of  the  media  which  continues  back  into  portions  of  the  internal 
iliac  artery.  There  is  also  a  growth  of  the  same  hyaline  connective 
tissue  which  has  extended  down  to  this  point  from  the  aorta.  A  few 
years  later  these  changes  have  reduced  the  opening  in  this  vessel  to 
a  short  and  narrow  tube.  Later,  all  that  is  seen  is  newly  formed 
sub-endothelial  elastic  membrane,  lining  the  remaining  cavity  of  the 
vessel,  surrounded  by  circular  muscular  fibres,  all  of  which  structure 
has  been  developed  in  the  new  tissue  which  closed  the  lumen  of  the 
vessel.*  According  to  Baumgarten  the  umbilical  (hypogastric)  artery 
in  the  adult  is  represented  by  a  thick,  hard,  round  cord,  one  and  one 
half  to  three  inches  in  length,  to  which  is  attached  a  more  delicate 
bundle  of  fibres  connecting  it  with  the  umbilicus.  This  cord  con- 
tains a  canal,  which  communicates  with  the  superior  vesical  artery, 
and  is  regarded  as  the  remains  of  an  imperfectly  obliterated  vessel. 
The  old  wall  of  the  vessel  can  be  made  out  throughout  all  this  part, 
except  at  the  upper  end,  where  the  media  and  the  adventitia  are 
somewhat  obscure,  but  the  elastic  membrane  can  still  be  seen.  The 
extreme  end  is  closed  by  fibrous  tissue.  With  the  exception  of  a 
small  fragment,  just  within  the  abdomen,  at  the  umbilical  end,  the 
vessel  is  not  obliterated,  according  to  the  old  view.  The  process  of 
partial  obliteration  is  complete  at  the  end  of  six  or  eight  weeks;  at 
the  end  of  four  or  five  months  the  arteries  are  attached  to  the  navel 
by  a  short  band  of  fibres,  which  contain  no  trace  of  the  vessel.  The 
band  of  fibres,  which  attaches  the  superior  vesical  artery  to  the 
umbilicus  in  adult  life,  he  concludes,  is  a  band  of  cicatricial  fibres, 
which  have  stretched  with  the  growth  of  the  individual,  the  umbilical 
artery  being  actually  about  the  same  length  that  it  was  at  birth. 
This  band  resembles  the  cord  which  unites  the  two  ends  of  a  vessel 
ligatured  in  continuity  which  have  retracted  and  stretched  apart. 
The  ductus  arteriosus  is  an  example  of  what  he  calls  the  "  typical  pro- 
cess of  incomplete  obliteration." 

In  order  that  the  following  series  of  reports  may  be  under- 
stood,  a  word    of  explanation   is   necessary.     The  ductus  was  re- 

*  "Dass  auch  musculose  Elemente  sich  in  den  bindegewebigen  Verdickungsschich- 
ten  der  Intima  der  Umbilical   Arterien  ausbilden   und  eine  regelmassig  gestaltete 
Ringsmusculatur  zusammensetzen." 
8 


114  TJie  Ligature  of  Ai-t cries. 

moved  with  a  small  portion  of  the  aorta  and  pulmonary  artery  still 
attached.  Before  closure  the  ductus  is  quite  a  tortuous  canal,  and, 
in  order  to  get  a  longitudinal  section  which  should  include  the  whole 
canal,  it  was  necessary  to  untwist  it  before  imbedding  the  specimen 
for  section.  The  sections,  which  showed  best  the  relations  of  the 
ductus  or  ligament  to  the  two  great  vessels,  were  those  giving  a  pro- 
file view,  that  is,  a  section  which  cut  the  specimen  longitudinally, 
and  at  the  same  time  followed  the  lines  of  axis  of  the  descending 
aorta.  These  sections  are  termed  the  longitudinal  vertical  sections. 
Those  made  in  the  longitudinal  plane  at  right  angles  to  this  are  called 
longitudinal-horizontal  sections.  Cross  sections  were  also  made, 
thus  observing  the  structure  from  every  point  of  view. 

Some  thirty  or  forty  specimens  were  examined  in  detail,  varying  in 
age  from  the  period  of  birth  to  seventy-five  years.  A  very  large 
number  of  sections  were  cut  from  each  specimen,  the  entire  liga- 
ment always  being  used  for  this  purpose.  In  some  cases,  every 
section  was  stained,  mounted  and  examined;  in  others,  all  were  care- 
fully inspected,  and  about  fifty  of  the  most  important  were  selected 
for  mounting.  When  cross  sections  were  taken,  the  specimens  were 
divided  into  several  small  segments,  the  locality  of  each  being  re- 
corded, and  in  this  way  no  difificulty  was  experienced  in  distinguish- 
ing the  aortic  end  from  the  pulmonary  end  or  the  intermediate 
portions. 

From  the  specimens  examined,  the  following  are  selected  as  show- 
ing the  different  points  of  interest  brought  out  in  the  investigation, 
the  prime  object  being,  of  course,  to  determine  the  nature  of  the 
cicatrix  in  the  aorta  at  the  point  of  insertion  of  the  ligamentum 
arteriosum. 

DUCTU.S    ARTERIOSUS. 
*~  At  Term. 

Longitudinal  vertical  sections  were  made  of  the  ductus  which 
was  still  open  and  contained  no  clot. 

The  canal  appears  to  be  narrowest  near  the  middle.  The  most 
striking  feature  of  its  walls  is  the  thickness  of  the  intima,  which 
widens  rapidly  at  its  point  of  junction  with  the  intima  of  the  large 
vessels:  its  surface  is  irregular,  indicating  the  presence  of  a  series  of 
transverse  folds  in  the  ductus,  due,  apparently,  to  a  contraction  in 
the  direction  of  its  axis.  It  consists  of  a  homogeneous,  transpar- 
ent matrix,  containing  a  large  number  of  cells  with  round  and  oval 


The  Closiu'c  of  the  Facial  J  "essr/s.  1 1 5 

nuclei.  The  cells  appear  to  run  from  the  deeper  layers  toward 
the  surface,  in  rows,  as  if  growth  were  taking  place  in  that  direction; 
there  do  not  appear  to  be  any  cells  of  a  distinctly  muscular  char- 
acter in  this  layer. 

The  media  also  differs  essentially  from  that  of  the  two  large 
vessels:  it  consists  of  bundles  of  cells,  running  chiefly  longitudin- 
ally, but  interlaced  with  circular  bands  of  similar  cells.  The  longi- 
tudinal bundles  are  seen,  in  the  sections  examined,  to  consist  of 
spindle-shaped  cells  packed  closely  together,  and  containing  elon- 
gated nuclei;  the  inner  bundles  extend  the  whole  length  of  the 
ductus,  but  the  outer  bundles  are  much  shorter,  and  this  peculiarity 
appears  to  be  due  to  the  projection  of  the  outer  portion  of  the  media 
of  the  large  vessels,  which  overlap  and  enclose  the  outer  portion  of 
the  media  of  the  ductus.  The  longitudinal  bundles  of  the  ductus 
interlace  with  the  elastic  fibres  of  the  media  of  the  vessels  for  some 
little  distance,  and  are  lost  in  that  layer.  The  adventitia  of  the 
vessels  and  ductus  consist  of  a  continuous  layer  of  tissue.  The 
boundary  line  between  the  intima  and  the  media  does  not  appear 
to  be  formed  by  any  well-marked  lamina  elastica,  the  longitudinal 
bundles  of  cells  serving  to  mark  the  inner  border  of  the  media. 
There  are  no  elastic  fibres  in  the  walls  of  the  ductus  other  than 
those  which  project  here  and  there  from  the  media  of  the  pulmonary 
artery  and  aorta. 

Remarks. — The  tissue,  of  which  the  ductus  is  composed,  is  of 
the  eml^ryonic  cellular  type;  there  is  no  sharply  defined  outline 
separating  its  different  coats,  and  its  walls  appear  to  be  strengthened 
by  projections  from  the  outer  coats  of  the  aorta  and  pulmonary 
artery. 

DUCTUS   ARTERIOSUS. 

A  Few  Days  After  Birth. 

Longitudinal  vertical  sections  were  made.  The  openings  of  the 
ductus  into  the  pulmonary  artery  and  the  aorta  were  still  of  the  size 
seen  before  birth,  but  there  was  some  contraction  in  the  centre  of 
the  duct,  which  was  also  twisted  one  and  one  half  times  upon  itself. 
Although  water  would  still  filter  through,  the  blood  had  probably 
ceased  to  flow.     No  clot  was  found. 

The  intima  thickens  rapidly  from  its  point  of  origin  from  the 
intima  of  the  great  vessels:  in  the  centre  it  is  rolled  up  into  thick 
and  pendulous  folds.  The  cells,  of  which  it  is  composed,  are  chiefly 
connective  tissue  cells,  but  there  are  undoubtedly  also  muscular  cells 


ii6  The  Li  gat  211' e  of  Arteries. 

to  be  found  singly  and  in  bundles,  in  this  layer,  such  cells  having 
been  carefully  observed  with  high  powers. 

Traces  of  the  lamina  elastica  can  be  seen  near  the  ends  of  the 
duct,  but  in  the  greater  portion  of  its  extent  no  lamina  can  be  found. 

The  media  consists  of  alternate  longitudinal  and  circular  bands 
of  muscular  cells,  the  former  lying  next  to  the  intima.  The  elastic 
fibres  of  the  mediae  of  the  large  vessels  are  continued  in  between 
these  bundles,  where  they  are  gradually  lost,  the  outer  fibres  extend- 
ing the  longest  distance.  The  longitudinal  bands  of  the  media  of 
the  ductus  can  also  be  traced  into  the  media  aortje  adjoining  the 
lower  edge  of  the  opening  into  the  aorta,  where  they  disappear. 

Some  portions  of  the  media  and  intima  have  begun  to  undergo 
a  hyaline  degeneration,  but  most  of  the  tissue  remains  as  yet  un- 
changed. 

The  walls  of  the  aorta  and  pulmonary  artery  adjacent  to  the 
openings  of  the  ductus  have  as  yet  undergone  no  change.  The 
muscular  and  elastic  layers  of  the  intima  aortre,  which  is  found  at 
the  lower  border  of  the  opening,  show  well  in  this  case. 

DUCTUS    ARTERIOSUS. 
Twenty-Eight    Days. 

This  specimen  was  cut  transversely.  The  duct  has  collapsed,  and 
the  lumen  shows  in  section  like  two  C's  placed  back  to  back;  but  it 
is  still  pervious.  The  thick  intima  of  the  ductus  is  still  seen  but 
has  undergone  a  partial  hyaline  degeneration,  a  few  cells,  here  and 
there,  still  taking  the  coloring  matter  well. 

The  inner  surface  is  lined  with  a  layer  of  endothelial  cells. 
The  elastic  lamina  shows  clearly  and  is  thrown  into  deep  folds; 
but  it  is  not  always  a  continuous  membrane.  Immediately  outside 
of  this  layer  are  bundles  of  longitudinal  fibres,  more  numerous  on 
one  side  than  on  the  other;  they  are  undergoing  a  hyaline  degenera- 
tion. They  are  surrounded  by  a  layer  of  spindle-shaped  cells  en- 
circling the  ductus,  which  are  arranged  singly  and  in  bundles,  and 
appear  to  be  in  a  state  of  active  proliferation.  There  are  also  a 
few  bands  of  longitudinal  cells  in  this  layer.  Near  the  pulmonary 
end  the  intima  has  undergone  more  completely  the  hyaline  degen- 
eration, and  there  are  not  so  many  bundles  of  circular  fibres.  The 
remains  of  the  foetal  longitudinal  fibres  predominate  here.  There 
is  a  moderate  round-cell  infiltration  in  some  parts  of  the  media. 
At  the  aortic  end  the  thick  intima  disappears,  and  in  cross  sections. 


The  Closure  of  the  Fa^tal  Vessels.  iiy 

the  arrangement  of  the  muscular  fibres  appears  quite  irregular. 
The  foetal  remains  appear  chiefly  in  the  inner  margins  of  the 
section,  which  shows  an  open  lumen  here;  at  some  points  foetal 
tissue  extends  quite  deeply  into  the  middle  coat. 

Remarks. — The  ductus  has  collapsed  but  has  not  become  obliter- 
ated. The  foetal  structures  are  in  process  of  elimination.  A  wall 
of  new  tissue  is  forming  on  the  outside  of  the  duct. 

LIGAMENTUM    ARTERIOSUM. 
Thirty-Five    Days. 

Longitudinal  vertical  sections  were  made.  The  central  portions 
of  the  ligament  consist  of  the  walls  of  the  ductus  in  a  state  of 
hyaline  degeneration.  A  slit  in  the  centre  of  this  material  marks 
the  site  of  the  former  lumen.  It  appears  to  communicate  with  the 
large  vessels  by  a  narrow  sinus  or  vessel  lined  with  endothelium. 
Surrounding  this  degenerated  tissue,  and  forming  the  outer  wall  of 
the  ligament,  are  bands  of  longitudinal  and  circular  muscular  fibres, 
which  appear  to  be  made  up  both  of  the  outer  layers  of  the  walls  of 
the  ductus,  and  of  cells  which  have  grown  from  the  adjacent  media; 
of  the  great  vessels. 

An  examination  of  the  aortic  end  shows  that  the  opening  has 
been  closed  partly  by  an  approximation  of  the  opposing  edges  of 
the  media  aortje  and  partly  by  a  growth  of  the  intima  aortae,  which 
is  greatly  thickened  at  this  place,  and  fills  the  remaining  space. 
Through  the  centre  of  this  tissue,  which  is  hyaline  and  rich  in  cells, 
runs  the  residual  vessel  above  referred  to.  Many  of  the  cells  which 
are  found  at  this  point  of  the  aorta  appear  to  spring  from  the  upper 
layers  of  the  media,  the  lower  layers  of  that  coat  diverging  con- 
siderably to  become  continuous  with  the  outer  walls  of  the  ligament. 
The  intervening  space  is  filled  with  the  degenerated  tissue  of  the 
ductus,  which  by  its  peculiar  staining  can  be  traced  for  some  distance 
into  the  media  of  the  aorta  on  either  side. 

The  arrangement  at  the  pulmonary  end  is  not  essentially  dif- 
ferent. 

There  is  a  peculiarity  of  the  intima  of  the  great  vessels  which 
deserves  notice  and  exists  on  one  side  only  of  the  openings  into 
them;  in  the  aorta  on  the  lower  side,  and  in  the  pulmonary  artery 
on  the  upper  side  of  the  opening,  or,  rather,  the  depression  marking 
the  site  of  the  old  opening.  The  aortic  wall  overhangs  the  upper 
margin  of  this  depression  as  an  eyebrow  overhangs  the  socket,  and 


Ii8  TJic  Ligature  of  Arteries. 

there  is  a  sharp  curve  in  the  fibres  of  the  media  at  this  spot,  when 
seen  in  section.  The  intima  appears  here  as  a  thin  layer  resting 
upon  the  elastic  lamina.  It  becomes  rapidly  thickened,  as  it  de- 
scends into  the  depression,  and  helps  to  fill  up  and  round  out  its 
deeper  portion.  It  does  not,  however,  grow  thin  again,  as  it  rises 
on  the  opposite  side  of  the  depression  and  continues  downward  on 
the  lower  wall  of  the  aorta,  but  remains  as  a  thick  layer  of  hyaline 
connective  tissue,  covered  by  a  layer  of  endothelium.  The  line  of 
demarcation  between  the  intima  and  the  media  aortae  is  not  distinct 
on  this  side,  as  there  is  a  layer  of  muscular  and  elastic  tissue,  which 
appears  to  be  placed  inside  of  the  elastic  lamina  and  to  belong  to 
the  intima  aortcc.  This  layer  is  the  "  musculo-elastic "  layer  of 
Thoma,  existing  only,  according  to  him,  just  below  the  orifice  of 
the  ductus. 

Remarks. — Most  of  the  foetal  tissue  of  the  walls  of  the  ductus 
has  undergone  degeneration  and  is  surrounded  by  a  muscular  layer, 
which  is  continuous  with  the  media  of  the  great  vessels.  The 
opening  into  the  aorta  has  been  closed  by  an  approximation  of  the  ad- 
jacent walls,  a  thickening  of  the  intima  and  a  growth  of  cells  from 
the  media. 

LIGAMENTUM    ARTERIOSUM. 

FoRTV-Two    Days. 

This  specimen  was  cut  into  longitudinal-horizontal  sections,  so 
that  all  of  the  aorta  seen  in  section  was  on  the  same  level.  There 
is  a  peculiarity  in  this  specimen  not  found  in  any  of  the  specimens 
examined.  The  central  portion  of  the  duct  had  not  collapsed  and 
was  distended  with  a  clot.  Obliteration  had  taken  place  in  this 
case  by  a  closure  of  the  two  ends,  and  not  by  an  hour-glass  contrac- 
tion of  the  centre  of  the  duct,  as  is  usually  said  to  be  the  case. 

The  clot  occupies  about  two-thirds  the  length  of  the  ligament 
and  is  a  little  nearer  the  aortic  than  the  pulmonary  end:  it  is  sur- 
rounded by  the  walls  of  the  ductus  in  a  state  of  advanced  hyaline 
degeneration,  no  cell-structure  being  seen  in  them.  This  degenera- 
tive change  appears  to  have  involved  the  intima  and  the  greater 
portion  of  the  media  but  not  all  of  the  latter  coat,  for  its  outer  layer 
still  exists  as  longitudinal  and  circular  bundles  of  fibres  which  have 
been  reinforced  by  growth  from  the  outer  portions  of  the  mediae  of 
the  large  vessels.  At  the  aortic  end  we  see  the  opening  through  the 
aortic  wall  has  become  obliterated,  partly  by  a  growth  from  aortic 


TJic  Closure  of  tJie  Footal   Vessels.  119 

media,  and  partly  by  a  growth  from  the  aortic  intima.  The  latter 
growth  consists  of  a  connective  tissue  composed  of  spindle-shaped 
cells  in  a  transparent  intercellular  substance;  it  is  pierced,  at  its 
centre,  by  a  small  vessel  which  soon  breaks  up  into  capillary 
branches. 

The  adjacent  edges  of  the  aortic  media  are  crowded  with  new 
muscular  cells  for  some  distance  and  many  of  these  cells  have 
grown  into  the  transparent  tissue  of  the  cicatrix.  The  growth  of 
cells  comes  chiefly  from  the  inner  half  of  the  aortic  media,  the  outer 
half  diverging  to  enclose  the  ligament  and  form  its  outer  wall  (Fig. 
30).  Between  the  diverging  portions  we  can  trace  the  hyaline  de- 
generated fibres  of  the  ductus. 

At  the  pulmonary  end  a  similar  condition  exists,  except  that 
the  thrombus  is  not  seen  and  the  duct  is  completely  closed.  The 
approximated  edges  of  the  media  and  the  thickened  intima,  pierced 
by  a  capillary  vessel,  show  here,  but  the  picture  is  not  so  pro- 
nounced. 

Remarks. — This  specimen  was  selected  for  illustration  as  the 
contrast  between  the  different  tissues  was  strong,  but  it  must  be 
remembered  that  the  presence  of  a  thrombus  is  exceptional.  We 
see,  at  the  aortic  end,  conditions  closely  resembling  the  cicatrix  in 
an  artery  after  ligature  in  continuity,  namely:  the  slightly  separated 
edges  of  the  media,  between  which  is  a  transparent  tissue,  contain- 
ing spindle  or  muscular  cells  and  pierced  by  a  central  arteriole. 

LIGAMENTUM    ARTERIOSUM. 
Eighteen  Months. 

Deep  dimples  in  the  aorta  and  pulmonary  artery  mark  the  site  of 
insertion  of  the  ligament,  which  is  bent  at  a  right  angle  soon  after 
leaving  the  artery,  and  turns  to  be  inserted  at  a  very  oblique  angle 
into  the  aorta.  It  is  quite  short.  Longitudinal  sections  were  taken 
in  a  horizontal  plane. 

Nearly  all  trace  of  the  ductus  has  disappeared,  a  few  transparent 
islets  of  tissue  still,  however,  remaining. 

The  new  tissue  consists  of  bundles  of  spindle-shaped  cells,  running 
longitudinally,  with  fibrous  intercellular  substance.  In  the  centre  is 
an  arteriole,  or  vessel  of  about  that  size,  opening  from  the  aorta,  and 
diminishing  gradually  in  size  until  it  apparently  opens  into  the 
pulmonary  artery  as  a  capillary  vessel.  This  vessel  at  its  aortic  end 
has  a  distinct  lamina  elastica  of  its  own,  the   longitudinal  folds  of 


I20  The  LigatJirc  of  Arteries. 

which  are  quite  distinct  with  a  low  power.  It  is  lined  with  a  delicate 
endothelium.  The  hyaline  tissue  through  which  it  runs,  is  crowded 
with  cells  of  new  growth  continuous  with,  and  of  the  same  character 
as,  those  in  the  ligament.  The  edges  of  the  media  are  seen  on 
either  side  of  the  tissue,  and  the  muscular  cell-growth  is  quite  active, 
both  at  the  edges  and  in  the  substance  of  the  media.  In  the  deeper 
layers  of  the  intima  are  seen  longitudinally  disposed  muscular  cells, 
which  run  down  into  the  cicatricial  tissue.  The  surface  of  the 
aortic  cicatrix  is  covered  by  the  connective  tissue  layer  of  the 
intima  and  endothelium.  At  the  pulmonary  end  the  media  has 
lost  much  of  its  arterial  character  and  is  now  much  less  muscular  in 
appearance. 

Circular  muscular  fibres  are  still  seen  surrounding  the  ligament 
in  its  whole  length. 

LIGAMENTUM    ARTERIOSUM. 
Five   Years. 

Longitudinal-vertical  sections  were  made.  A  sinus  runs  in  about 
half  the  length  of  the  ligament,  apparently  communicating  with  the 
aorta,  but  no  endothelial  lining  could  be  demonstrated.  At  its  apex 
a  capillary  vessel  is  given  off,  which  communicates,  in  a  pretty  direct 
course,  with  the  pulmonary  artery.  The  upper  portion  of  the  aorta 
overhangs  the  opening,  like  a  brow,  the  media  taking  a  sharp  curve 
backward  in  the  section:  the  lower  wall  slants  at  an  obtuse  angle. 
The  intima  is  slightly  thickened  at  the  upper  margin  of  the  orifice, 
and  increases  rapidly,  in  thickness,  just  opposite  the  opening,  but 
begins  to  grow  narrower  a  short  distance  below.  It  appears  to  consist 
chiefly  of  a  connective  tissue  layer  on  which  rests  the  endothelium. 
In  it  are  seen  remains  of  the  foetal  tissue.  The  fibres  of  the  media 
aortae  run  on  either  side,  in  a  shelving  manner,  into  the  compact 
bundle  of  longitudinal  fibres,  of  which  the  ligament  appears  to  be 
compo'sed.  Muscular  cells  are  seen,  running  longitudinally,  through 
the  whole  length  of  the  ligament,  but  are  not  as  numerous  as  in  the 
previous  specimens.  A  patch  of  calcareous  matter  marks  the  former 
site  of  unabsorbed  fcetal  tissue.  There  are  bundles  of  circular 
fibres  on  the  periphery  of  the  ligament. 

Remarks. — The  process  of  closure  is  probably  completed  in  this 
case,  although  a  portion  of  the  ligament  is  pierced  by  a  sinus  of 
considerable  calibre.  The  fibrous  character  of  the  ligamentous 
tissue  becomes  clearly  marked,  and  the  free  growth  of  cells  into  it 
from  the  mediae  of  the  ereat  vessels  is  also  noticeable. 


The  Closure  of  the  Fatal   l^essels.  1 2,1 

LIGAMENTUM    ARTERIOSUM. 
Thirty-Eight   Years. 

The  peculiarity  of  this  specimen  consists  in  the  absence  of  any 
dimple  or  cicatricial  depression  marking  the  point  of  insertion  of 
the  ligament  into  the  aorta.  The  ligament  is  quite  short  and  consists 
of  a  cord  of  longitudinally  arranged  elastic  and  non-elastic  fibres. 
A  very  small  vessel  enters  at  the  pulmonary  end,  where  the  usual 
depression  exists,  and  extends  the  whole  length  of  the  ligament, 
terminating  in  a  capillary  network  in  the  aortic  wall.  Sections  were 
taken  longitudinally  and  in  a  vertical  plane,  so  that  the  aortic  end 
is  seen  in  profile  (Fig.  31).  The  layers  of  the  aortic  wall,  at  this 
point,  consist,  first,  of  the  usual  layer  of  endothelium,  beneath 
which  is  a  thickened  layer  of  connective  tissue-cells,  in  transparent 
matrix,  tapering  off  rapidly  above  and  below.  Beneath  this  lies  the 
muscular  elastic  layer  of  the  intima,  so-called,  the  elastic  elements 
of  which  are  unusually  pronounced,  which  forms  over  the  ligament, 
a  thick  and  prominent  layer,  and  fills  out  the  space  between  the 
edges  of  the  media  with  branching  elastic  fibres,  presenting  an 
open  meshwork,  in  which  few  cells  are  found.  They  are  to  be  seen, 
however,  in  considerable  numbers  in  its  deeper  layers,  which  adjoin 
the  media.  The  edges  of  the  media  are  still  slightly  separated, 
and  taper  off  considerably,  as  they  turn  downwards,  and  become 
continuous  with  the  fibres  of  the  ligament  with  which  the  fibres  of 
the  lower  aortic  wall  are  nearly  parallel.  The  fibres  of  the  liga- 
ment are  mingled  chiefly  with  those  of  the  descending  portion  of 
the  aortic  wall,  but  a  portion  of  them  take  a  graceful  curve  back- 
wards, and  are  lost  in  the  upper  wall.  At  the  point  of  divergence 
of  these  two  bundles  is  a  little  loose  tissue  in  which  a  bunch  of 
capillary  vessels  is  seen.  At  the  edges  of  the  media,  which  are  not 
sharply  defined,  there  is  a  growth  of  muscular  cells,  and  cells  of  a 
similar  character  may  be  seen  in  smaller  numbers  between  the  fibres 
of  the  ligament.  The  outer  layer  of  circular  muscular  cells  is  also 
seen  in  the  ligament,  Init  is  now  quite  subordinated,  A  few  patches 
of  calcification  appear  here  and  there. 

Remarks. — We  see  here  the  fully  developed  ligament,  which 
consists  of  fibrous  and  elastic  tissue,  forming  a  dense  band.  At  the 
aortic  end  the  cicatrix  consists  of  cells,  coming  from  the  still  slightly 
separated  edges  of  the  media,  and  a  thick  layer  of  elastic  fibres 
and  plates,  which  fills  up  and  obliterates  the  usual  depression  in  the 
wall.     The  cicatrix   in  the  aortic  wall   rnay  be  said,  in  this  case,  to 


122  TJie  Ligature  of  Arteries. 

consist  of  fibrous  and  elastic  tissue  intermingled  with  muscular 
cells.  It  should  be  noted  that  in  this  case  the  circular  muscular 
fibres  of  the  ligament  are  imperfectly  developed. 

LIGAMENTUM   ARTERIOSUM. 
Forty-Two   Years. 

The  ligament  is  short  and  terminates  in  the  characteristic  de- 
pression in  the  vessels  at  each  end.  Longitudinal  sections  in  a  ver- 
tical plane  were  made.  In  the  centre  between  the  usual  dense 
bundles  of  fibrous  and  elastic  tissue  is  seen  a  mass  of  loose  cellular 
tissue,  in  which  a  capillary  network  ramifies.  This  tissue  occupies 
the  axis  of  the  ligament  in  its  entire  length,  except  at  the  points  of 
its  insertion  into  the  great  vessels,  where  the  longitudinal  fibres  are 
collected  into  one  dense  bundle  before  they  spread,  to  lose  them- 
selves in  the  coats  of  those  vessels.  At  the  aortic  end  the  upper  wall 
of  the  aorta  overhangs  the  depression,  brow-like,  and,  from  the 
apex  of  the  depression,  an  arteriole  makes  its  way  to  the  capillary 
network  in  the  ligament.  (Fig.  29.)  The  elastic  layer  of  the  intima 
forms  a  thick  wall  around  the  arteriole,  but  there  are  few  cells  in  it. 
Inside  of  this  layer  is  the  connective  tissue  layer  which  is  slightly 
thickened  here:  muscular  cells  are  seen  at  the  edges  of  the  media 
surrounding,  in  longitudinal  and  circular  rows,  the  arteriole,  and 
also  in  the  walls  and  between  the  fibres  of  the  ligament. 

At  the  pulmonary  end  there  is  the  customary  vessel,  which  com- 
municates with  the  capillary  network.  The  usual  condition  of  the 
walls  of  this  large  vessel  prevails  in  this  case. 

Remarks. — The  appearance  of  the  aortic  cicatrix  is  a  fair  sample 
of  the  conditions  usually  found.  In  the  centre  of  the  ligament 
the  loose  areolar  tissue  seen  is  found  in  only  a  limited  number  of 
specimens.  It  suggests  the  pre-existence  of  a  thrombus  such  as  was 
seen  in  the  specimen  taken  from  a  child  forty-two  days  old. 

LIGAMENTUM   ARTERIOSUM. 

FoRTv-Two   Years. 

Longitudinal  sections  were  made  m  a  horizontal  plane.  The 
Hgament  shows  as  a  band  of  densely  packed  elastic  and  fibrous 
tissue  with  few  cell-elements.  In  the  central  axis  there  are  seen, 
here  and  there,  traces  of  a  capillary  vessel.  Its  fibres  divide  equally 
at  the  aortic  end,  and  lose  themselves  in  the  central  portions  of  the 
coats   of  that  vessel,  the    intima  aorta  being  continued    over  the 


\ 


The  Closure  of  the  Ftvtal   Vessels.  123 

surface  of  the  point  of  insertion,  and  the  outer  portions  of  the 
media  aortse  being  continued  down  upon  the  outer  walls  of  the  liga- 
ment. There  is  no  vessel  communicating  with  the  aorta,  and  the 
depression  in  that  vessel  is  a  slight  one.  No  vessel  is  found  com- 
municating with  the  pulmonary  artery.  There  is  no  trace  of  degen- 
erated tissue  to  be  seen  in  any  of  the  sections  taken  from  this 
specimen. 

Remarks. — The  appearance  of  the  aortic  walls  in  sections  taken 
horizontally  is  quite  different  from  those  taken  in  a  vertical  plane. 
In  the  former  case,  the  media  seems  to  form  a  continuous  layer 
over  the  cicatrix,  the  continuity  of  its  fibres  being  but  slightly  broken 
by  those  of  the  ligament.  In  the  vertical  section,  it  will  be  seen 
that  there  is  an  appreciable  interval  between  the  edges  of  the 
media. 

LIGAMENTUM    ARTERIOSUM. 

Forty-Seven    Years. 

The  ligament,  which  was  quite  long,  was  cut  into  transverse 
sections.  Sections  taken  as  nearly  as  possible  through  the  aortic 
cicatrix  show  an  irregular  oval-shaped  mass  of  tissue,  surrounded  by 
the  media,  composed  of  white  and  elastic  fibres,  running  obliquely 
towards  the  observer;  there  is  no  well-defined  outline  between  this 
tissue  and  that  of  the  media,  the  cells  of  which  project  into  it.  In 
the  axis  is  a  single  capillary  vessel,  and  around  this  very  few  cells 
are  seen.  Abreast  of  the  adventitia  aortae  the  fibres  are  seen,  cut 
transversely:  the  cells  are  more  abundant:  longitudinal  bundles  of 
muscular  cells  are  seen  in  the  centre  of  the  ligament;  and  a  thin 
band  of  circularly  arranged  cells  forms  its  outer  border.  The 
bodies  of  the  longitudinal  cells  come  out  quite  distinctly  in  cross 
sections,  as  does  also  their  division  into  separate  bundles  by  trabe- 
culae.     No  elastic  membrane  is  seen  at  this  end. 

Nearer  the  middle  of  the  ligament  the  cells  are  less  numerous, 
although  the  circular  belt  of  cells  is  as  thick  as  elsewhere.  Islets 
of  calcification  are  seen  at  intervals.  Near  the  pulmonary  end 
traces  of  the  lamina  elastica  are  found,  and  nearer  still,  a  narrow 
slit,  lined  with  a  lamina,  is  seen.  The  end  in  section  is  an  elongated 
oval,  appearing  to  be  inserted  in  the  wall  of  the  artery,  between  two 
layers  of  the  fibres  of  the  media  which  have  been  stretched  apart 
to  admit  it.  Cells  are  more  numerous,  again,  in  this  end  of  the 
ligament. 

Remarks. — There  can  be  little  doubt  that  the  cells  found  at  the 


124  The  Ligatu7-e  of  Arteries. 

ends  and  sides  of  the  ligament  are  of  a  muscular  character,  and   so 
probably  also  are  many  of  those  in  the  central  axis. 

The  anatomical  structure  of  the  ductus  arteriosus  differs  materially 
from  that  seen  in  any  other  portion  of  the  arterial  system.  Some 
of  its  peculiarities  are  to  be  traced  in  the  hypogastric  artery,  but 
exist  there  in  a  much  less  marked  degree.  At  the  period  of  birth, 
and  before  any  structural  change  has  taken  place  in  its  walls,  it  is  a 
more  or  less  tortuous  canal,  running  obliquely  downward  from  the 
pulmonary  artery  to  the  aorta,  into  which  it  opens  just  below  the 
somewhat  sharp  curve  of  the  lower  border  of  the  arch,  at  the 
beginning  of  the  descending  aorta.  The  ends  of  the  duct  are 
still  open,  but  in  the  central  portions,  the  walls  are  approximated, 
partly  from  the  twisting  of  the  vessel  which  is  now  empty,  and  partly 
from  a  contraction  of  the  walls.  Water  will,  however,  readily  trickle 
through  the  canal.  The  inner  coat  forms  one  of  the  most  marked 
peculiarities  of  this  canal,  owing  to  its  great  thickness,  which,  how- 
ever, varies  considerably  at  different  points,  giving  an  extremely 
irregular  wavy  outline  to  the  surface  of  that  layer,  when  seen  in 
longitudinal  section.  This  condition  is  probably  more  apparent  than 
real,  the  inequality  being  largely  due  to  the  twists  and  curves  of  the 
lumen,  which  render  it  impossible  to  cut  this  layer,  in  all  its  parts, 
at  the  same  angle.  The  cells  of  which  it  is  composed  lie  in  a 
transparent  intercellular  substance,  and  are  spindle-shaped:  they 
are  arranged  for  the  most  part  longitudinally,  although  this  is  not 
always  apparent,  owing  to  the  irregularities  mentioned.  By  some 
observers  they  are  supposed  to  be  connective  tissue  cells,  by  others, 
muscular.  The  more  superficial  cells  do  not,  as  a  rule  present  the 
type  of  the  muscular  cell,  but  very  perfect  examples  of  the  mus- 
cular cells  are  seen  in  the  deeper  layers  of  the  intima.  The  bound- 
ary lines  of  the  different  coats  are  exceedingly  indistinct.  The 
lamina  elastica  is  not  easily  found  in  the  longitudinal  sections,  and 
does  not  appear  to  be  continuous,  being  wanting  at  many  points. 
It  is  more  easily  made  out  in  cross  sections. 

The  media  consists  chiefly  of  bands  of  longitudinally  arranged 
.-nuscular  cells;  these  are  occasionally  separated  from  one  another 
by  circular  bands  of  muscular  cells  chiefly  at  the  outer  border  of  the 
vessel.  The  coat  is  almost  entirely  a  cellular  one.  The  few  elastic 
fibres  which  it  contains  can  be  traced  into  the  aorta  and  pulmonary 
artery;  they  are  most  abundant  in  the  outer  layers  of  this  coat, 
and  occasionally  extend  throughout  its  whole  length. 


TJic  Closure  of  the  Fecial  ] 'esse Is.  125 

At  the  aortic  opening  the  intima  narrows  rapidly  on  either  side; 
at  its  upper  margin  the  aortic  wall  makes  a  sharp  curve  upward,  when 
seen  in  longitudinal-vertical  sections,  to  form  the  lower  curve  of 
the  aortic  arch.  Here  a  thin  layer  of  cells  lying  upon  the  elastic 
lamina,  which  is  well  defined,  forms  the  intima  aorta.  The  walls 
of  the  aorta,  at  the  lower  margin  of  the  opening,  are  thicker,  and 
are  continuous  in  a  nearly  straight  line  with  the  tissue  of  the  ductus; 
the  tissues  of  the  coats  of  the  aorta  and  ductus  are  interwoven  at 
this  point,  and  those  of  the  ductus  are  spread  out  in  a  fan-like  shape, 
and  are  lost  in  the  different  layers  of  the  wall  of  the  aorta.  The 
elastic  lamina  of  the  aorta  does  not  form  here  a  continuous  layer, 
as  above,  but  is  broken  into  several  more  or  less  parallel  layers. 
According  to  Thoma,  that  portion  of  the  wall  which  lies  inside  of 
the  principal  elastic  layer,  belongs  to  the  intima,  and  is  described 
by  him  as  the  musculo-elastic  layer  of  the  intima  which  forms  a  rein- 
forcement to  the  wall  at  this  particular  point.  A  similar  arrangement 
of  the  elastic  lamina  is  found  elsewhere  in  the  aorta,  and  it  would 
seem  to  have  no  significance  at  this  spot  further  than  as  an  indica- 
tion of  the  tendency  of  the  elastic  tissue  to  form  less  of  a  limiting 
membrane  in  the  neighborhood  of  the  ductus,  where  all  layers 
are  ill  defined.  The  intima  of  the  ductus  narrow's  rapidly,  as  it 
emerges  at  the  lower  border,  and  becomes  continuous  with  a  simi- 
lar layer  of  cells,  here  appearing  as  connective  tissue  cells,  which 
form  a  narrow  layer  in  the  intima  of  the  descending  aorta.  This 
layer  was  traced  about  half  an  inch  below  the  opening  of  the  duc- 
tus, at  various  periods  from  birth  up  to  adult  life,  but  was  not  found 
to  form  the  thick  layer  described  by  Thoma  as  lining  the  interior 
of  the  aorta  between  this  point  and  the  iliac  artery  after  birth. 

The  arrangement  of  the  walls  of  the  pulmonary  arter}-  resembles 
that  seen  at  the  aortic  opening,  but  in  a  reverse  order.  Here,  the 
upper  wall  is  the  thicker,  and  it  receives  the  tissues  of  the  upper 
wall  of  the  ductus  which  are  freely  interlaced  with  it.  The  differ- 
ence between  the  two  margins  of  the  pulmonary  opening  is  not  so 
marked  as  at  the  aortic  end. 

A  few  weeks  after  birth  a  very  marked  change  has  taken  place 
in  all  the  tissues  of  the  ductus,  which  appear  to  be  now  undergoing 
hyaline  degeneration,  preparatory  to  absorption.  The  outermost 
walls  alone  remain,  but  it  is  not  certain  whether  the  structures, 
still  preserved  from  degeneration,  should  not  be  regarded  as  belong- 
ing to  the  aorta  and  pulmonary  artery.  A  few  weeks  later,  this 
outer  wall  is  found  to  have  become  greatly  strengthened,  and  now 


126  TJic  Ligature  of  Arteries. 

forms  a  layer  of  circular  muscular  fibres,  which  enclose  the  tissues 
of  the  ligament,  and  is  continuous  with  the  mediae  of  the  two  great 
vessels. 

At  this  period  the  margins  of  the  media  aorta;  at  the  aortic 
opening  are  greatly  approximated  by  the  obliteration  of  that  orifice. 
The  intima  forms  a  thickened  layer  which  partially  fills  out  the 
umbilicated  depression  in  the  aortic  wall  and  the  space  still  interven- 
ing between  the  ends  of  the  media.  (Fig.  30.)  Here  it  forms  a 
hyaline  tissue  pierced  by  a  small  arteriole  apparently  of  new  forma- 
tion, its  cellular  elements,  consisting  of  cells  growing  from  the  intima 
and  media.  The  latter  coat  is  divided  into  an  inner  and  an  outer 
layer  which  diverge  slightly,  the  inner  directed  toward  the  cicatri- 
cial tissue,  the  outer  being  continuous  with  the  outer  layers  of  the 
ligament.  Between  these  two  layers  lies  the  degenerated  tissue  of 
the  ductus  (Fig.  30).  From  the  inner  layer  an  active  cell-prolifera- 
tion is  taking  place,  and  with  high  powers  a  beautiful  mass  of 
muscular  cells  is  seen,  growing  in  profusion,  leaving  little  doubt  as 
to  the  part  played  by  the  media  in  the  healing  process. 

In  Fig.  30,  the  walls  of  the  ductus  are  represented  as  open  in 
the  middle  portion;  in  the  specimen  the  space  was  occupied  by  a 
thrombus.  The  formation  of  a  thrombus  does  not  appear  to  be 
usual,  and  is  probably  due  to  a  more  active  contraction  at  the  ends 
of  the  ductus,  than  at  its  centre.  In  many  adult  specimens  a  cleft  or 
sac  is  seen  occupying  a  considerable  portion  of  the  centre  of  the 
ligament,  the  presence  of  which  is  probably  due  to  the  pre-existence 
of  a  thrombus. 

The  specimen  taken  from  a  child  eighteen  months  old  shows  a 
complete  development  of  the  ligamentum  arteriosum,  traces  only 
of  the  hyaline  degenerated  tissue  of  the  ductus  remaining.  Later 
in  life,  the  tissues  do  not  appear  to  undergo  any  essential  change 
other  than  a  degenerative  one,  calcification  of  certain  portions  of 
the  ligament  being  seen  at  all  ages  and  being  probably  due  to  further 
change  in  islets  of  unabsorbed  foetal  tissues. 

When  fully  formed,  the  ligament  consists  of  a  dense  bundle  of 
longitudinal  fibres  composed  of  fibrous  and  elastic  tissue;  these 
contain  a  moderate  number  of  cells  of  spindle  shape;  this  tissue 
is  enclosed  in  a  layer  of  circular  muscular  fibres  of  varying  thick- 
ness. Outside  of  all  is  the  adventitia  reflected  from  the  coats  of 
the  great  vessels.  In  the  central  axis  of  the  ligament  a  small 
vessel  is  usually  found  which  can  be  traced,  either  directly  or 
through  a  few  capillaries,  to  the  aorta  or  pulmonary  artery;    occa- 


The  Closure  of  the  Facial  Vessels.  12/ 

sionally  a  cleft  or  blood  space,  lined  with  endothelium,  is  seen  con- 
necting at  either  end  with  a  small  vessel.  Less  frequently  the  bundle 
of  fibres  of  which  the  ligament  is  composed  is  divided,  a  mass  of 
loose  areolar  tissue  occupying  the  space  between  them;  this  tissue 
usually  contains  a  rich  capillary  network.  The  areolar  tissue,  like 
the  sinus,  occupies  only  the  middle  portions  of  the  ligament,  which 
is  closed  with  a  denser  tissue  at  either  end.  At  the  aortic  end  of 
the  ligament,  when  studied  in  longitudinal  vertical  sections  (Figs. 
29  and  31,)  the  ends  of  the  media  aortae  are  seen  still  slightly 
separated.  The  fibres  of  the  ligament  seem  to  be  more  directly 
continuous  with  the  lower  wall  of  the  aorta.  In  the  greater  number 
of  specimens  the  indentation  of  the  wall  which  marks  the  site  of 
the  opening  remains  permanently,  and  can  be  seen  as  a  dimple  sit- 
uated beneath  a  sharp  ridge  or  brow,  formed  by  the  inferior  wall  of 
the  aortic  arch,  just  beyond  the  point  of  origin  of  the  occipital 
vessels.  The  edges  of  the  media  aortse  on  either  side  are  turned 
slightly  outwards  to  meet  those  fibres  of  the  ligament  which  lose 
themselves  chiefly  in  the  lower  wall.  Here  the  fibres  can  be  traced, 
not  only  into  the  media,  but  also  into  the  musculo-elastic  layer, 
so-called,  of  the  intima;  some  of  the  fibres  curl  upward  to  be  in- 
serted into  the  wall  at  the  upper  margin  of  the  opening,  and 
the  space  between  the  diverging  bundles  is  filled  out  by  a  growth 
from  the  more  superficial  layers  of  the  intima.  It  is  here  that  the 
small  arteriole  branching  from  the  aorta  is  usually  found.  The 
cells  are  much  more  numerous  in  the  tissues  just  described  than 
elsewhere  in  the  ligament,  and  many  of  them  are  of  a  distinctly 
muscular  character;  bundles  of  them  being  traced  into  the  media 
and  musculo-elastic  layer  Many  of  them  can  be  seen  surrounding 
the  small  central  arteriole. 

Occasionally  no  aortic  depression  is  found,  the  surface  being 
perfectly  smooth,  so  that  no  indication  is  given  of  the  exact  site  of 
the  aortic  cicatrix.  In  these  cases  an  unusual  development  of 
elastic  tissue  appears  to  have  taken  place  from  the  musculo-elastic 
layer,  so  that  the  depression  between  the  everted  edges  of  the  aorta 
has  been  completely  filled  up  (Fig.  31).  In  some  cases,  all  direct 
vascular  communication  appears  to  have  ceased. 

At  the  pulmonary  artery  end  there  is,  invariably,  a  symmetrical 
depression,  and  the  nature  of  the  healing  of  that  wall  does  not 
differ  essentially  from  the  most  common  form  of  aortic  cicatrix. 

An  analysis  of  the  nature  of  the  cicatrix  in  the  aortic  wall,  the 
feature  of  the  ligamentum   arteriosum  of  most  interest,  in  the  pres- 


128  TJic  Ligature  of  Arteries. 

ent  connection,  gives  a  combination  of  tissues  closely  resembling 
that  found  in  the  cicatrix  of  large  arterial  trunks  after  ligature 
in  continuity.  The  slightly  separated  edges  of  the  media  stand 
out  distinctly  from  the  other  tissues:  between  them  lies  the  new 
tissue,  which,  in  some  cases,  consists  of  a  hyaline  basis  filled  with 
muscular  cells,  and  perforated  by  a  central  arteriole.  This  layer 
tapers  off,  on  either  side,  becoming  continuous  with  the  intima;  at 
other  times,  the  hyaline  tissue  is  partly  replaced  by  a  considerable 
formation  of  elastic  tissue,  a  condition  not  seen  in  arteries,  but 
which  one  would  expect  to  find  in  a  vessel  containing  so  large  a 
predominance  of  elastic  fibres  as  the  aorta.  The  presence  of  a 
layer  of  circular  muscular  fibres  in  the  ligament,  does  not  seem  to 
bear  out  the  analogy,  which  might  be  expected,  with  the  cord  which 
unites  the  two  ends  of  an  artery.  In  the  largest,  and  most  powerful 
arterial  cicatrices,  we  find  the  new  tissue  enclosed  for  a  considerable 
distance  by  an  arterial  wall  (Fig.  27),  giving  the  support  needed  at 
a  point  where  the  blood  pressure  would  cause  a  severe  strain  upon 
the  cicatricial  tissue.  In  the  aorta,  the  obliquity  of  the  insertion 
of  the  ligamentum  arteriosum,  and  the  overhanging  edge  at  the 
upper  margin  of  the  cicatrix,  give  a  valve-like  action  to  the  ends  of 
the  media  aortse  which  are  pressed  together,  rather  than  separated, 
during  the  dilatation  of  that  vessel. 

A  study  of  the  obliteration  of  the  ductus  affords  additional 
proof  of  the  power  of  the  muscular  elements  to  form  new  tissue. 
The  activity  of  these  cells  was  observed  in  a  number  of  speci- 
mens, examined  a  few  weeks  after  birth,  and  the  developed  cica- 
trix shows  bundles  of  cells,  which  not  only  resemble  muscular  cells, 
in  their  shape  and  size,  but  which  can  be  traced  directly  into  the 
media,  and  the  musculo-elastic  layer  of  the  intima,  where  muscular 
cells  are  always  found  in  abundance.  The  changes  seen  in  the  wall 
of  the  ligament  are  alone  sufficient  proof  of  the  power  of  this  cell 
to  take  part  in  formative  processes,  a  role  which,  curiously  enough, 
has  been  almost   universally  denied  to  it  by  pathologists. 

THE    HYPOGASTRIC    ARTERY. 

The  other  vessel  closed  by  nature  at  the  time  of  birth  is  oblit- 
erated under  circumstances  which  correspond  pretty  accurately  to 
those  which  obtain  in  the  artery  of  an  amputation  stump.  A  large 
portion  of  the  territory  supplied  by  the  vessel  is  permanently  re- 
moved, and  the  blood  which  now  flows  through  it  is  distributed  to  an 
area  of  comparatively  limited  extent.     There  is  no  longer  need  of 


The  Closure  of  tJic  Fatal  J^ssols.  129 

a  vessel  of  the  calibre  of  the  hypogastric  artery,  and  the  changes, 
which  ensue,  should  affect  the  vessel  in  its  whole  extent.  I'hat 
such  a  result  follows  is  a  well-known  anatomical  fact;  the  remains 
of  the  hypogastric  artery  subsequently  doing  service  as  the  superior 
vesical  artery.  The  observations  of  Baumgarten  are  intended  to 
show  that  the  old  vessel  remains  entire,  and  is  not  destroyed  as 
had  been  taught  by  Virchow.  Thoma's  studies  have  led  him  to 
express  the  opinion  that  a  growth  takes  place  from  the  intima,  by 
which  the  calibre  of  the  vessel  is  narrowed,  and  that  new  walls  are 
thus  formed  within  the  old. 

The  following  examples  are  selected  from  a  number  of  observa- 
tions, made  to  determine  the  precise  nature  of  these  changes,  and 
to  supply  a  standard  with  which  to  compare  the  investigations  made 
upon  the  healing  of  arteries  after  amputation. 

On  laying  open  the  abdominal  cavity  of  an  infant,  the  hypo- 
gastric artery  can  be  readily  traced  from  the  uml)ilicus  to  the  brim 
of  the  pelvis,  just  beyond  which  point  it  merges,  with  the  internal 
iliac  artery,  into  the  common  iliac.  The  upper  portion  of  the  in- 
ternal iliac  artery,  an  exceedingly  small  vessel  at  this  period,  is  for 
the  time  being,  appropriated  by  the  placental  circulation.  In  re- 
moving" the  specimen,  the  point  of  junction  of  the  hypogastric  with 
the  internal  iliac  was  carefully  sought  for,  and  the  specimen  pre- 
served from  this  point  to  the  umbilicus  for  histological  study.  Each 
specimen  was  divided  into  segments,  so  that  the  different  portions  of 
the  vessel  could  be  studied  separately.  Both  longitudinal  and  trans- 
verse sections  were  made.  The  examples  presented  illustrate  the 
earliest  changes  which  take  place  at  and  soon  after  birth,  as  well  as 
the  completed  process  in  the  adult.  The  specimen  taken  from  the 
monkey  is  reported,  both  for  the  purpose  of  a  comparative  study, 
and  on  account  of  the  perfection  of  its  histological  details. 

THE   HYPOGASTRIC    ARTERY. 

Infant    a    Few    Days   Oi-d. 

On  laying  open  one  of  the  pair  of  vessels,  a  clot  about  one  and 
one  quarter  inch  in  length  was  found  at  the  umbilical  end  of  the 
vessel.  The  other  vessel  was  removed  from  the  point  of  bifurca- 
tion of  the  common  iliacs,  and  cut  into  four  equal  portions.  The 
first  portion  extended  from  the  bifurcation  of  the  common  iliac  to 
the  junction  of  the  hypogastric  artery  with  the  internal  iliac,  and 
was  cut  into  longitudinal  sections. 
9 


130  The  Ligature  of  Artei'ies. 

The  only  change  to  be  seen  here  is  an  appearance  of  sHght 
atrophy  of  the  portions  of  the  media,  that  coat  taking  the  coloring 
matter  less  perfectly  than  other  parts  of  the  vessel.  The  difference 
between  the  lamina  elastica  of  the  internal  iliac  and  its  equivalent 
in  the  hypogastric  artery  is  striking.  In  the  former  it  constitutes  a 
thick  and  glistening  membrane;  in  the  latter,  there  are  several 
elastic  layers  close  together,  no  one  of  which  is  well  pronounced, 
and  between  them  are  longitudinal  rows  of  muscular  cells. 

In  the  second  portion,  consisting  of  the  next  adjoining  segment, 
also  cut  into  longitudinal  sections,  we  trace  the  elastic  layers  just 
mentioned,  but  find  no  well-defined  lamina  elastica.  There  is  as 
yet  no  change  in  the  intima. 

In  the  third  portion,  beginning  at  the  middle  of  the  vessel  and 
extending  towards  the  peripheral  end,  cut  transversely,  we  meet 
with  numerous  bundles  of  longitudinal,  muscular  fibres  in  the  media. 
The  vessel  is  now  greatly  contracted,  and  the  wall  is  thrown  into 
longitudinal  folds.  Near  the  point  where  the  clot  terminates  there  is 
a  distinct  thickening  of  the  intima,  apparently  due  to  the  proliferation 
of  the  endothelial  cells.  These  cells  are  firmly  attached  to  the  apex  of 
the  thrombus.  There  is,  as  yet,  no  outgrowth  into  the  clot  or  lumen 
from  this  layer. 

In  the  fourth  portion,  or  that  part  attached  to  the  granulating  sur- 
face of  the  umbilicus  (cut  longitudinally),  we  find  the  terminal 
portion  of  the  vessel,  for  about  one  quarter  of  an  inch,  very  tor- 
tuous, collapsed,  containing  no  clot,  the  end  lying  exposed  among 
the  granulations.  The  walls  are  in  a  state  of  incipient  hyaline 
degeneration;  that  is,  the  elements  of  the  tissue  take  the  coloring 
matter  very  feebly,  their  outline  is  imperfect,  and  there  is  a  general 
condition  of  transparency  pervading  the  tissues  of  the  vessel.  This 
condition  extends  to  a  point  about  three  quarters  of  an  inch  from 
the  surface;  beyond  this  we  see  the  cell  structure  distinctly,  as 
before.  This  part  of  the  vessel  differs  from  the  more  proximal 
portions  in  the  diminished  amount  of  elastic  tissue,  the  vagueness 
of  outline  between  the  inner  and  middle  coats,  and  the  amount 
of  muscular  fibre  which  is  somewhat  greater  here. 

Remarks. — We  have  here  an  example  of  the  earliest  changes  to 
be  seen  after  the  circulation  in  the  umbilical  cord  has  ceased.  A 
thrombus  fills  almost  one  quarter  of  the  lumen  of  the  vessel,  a 
slight  growth  of  endothelium,  serves  to  attach  the  clot  firmly  to 
the  vessel-wall,  and  the  extreme  terminal  portion  of  the  vessel  is 
undergoing  a  hyaline  degeneration. 


TJie  ClosiD'c  of  the  Fcctal  Vessels.  131 

HYPOGASTRIC   ARTERY. 
Infant  Thirty-Six  Days  Old. 

The  umbilicus  was  removed  together  with  the  iHac  arteries.  At 
their  terminal  portions  the  two  hypogastric  vessels  united  to  form 
a  cord  of  hyaline  tissue  attached  to  the  umbilicus.  The  lumen  had 
become  obliterated  near  the  point  of  junction.  An  inch  of  each 
vessel  was  removed  at  this  end,  and  sections  were  made  transversely 
in  one,  and  longitudinally  in  the  other. 

Longitudinal  sections  include  the  closed  end  of  the  vessel.  The 
lumen  is  tortuous,  making  it  difficult  to  obtain  a  cut  of  a  continuous 
portion  of  the  vessel  of  any  length.  The  outer  coats  of  the  vessel 
are,  however,  quite  straight.  These  consist  of  embryonic  connective 
tissue,  of  which  the  cord,  to  which  the  two  vessels  are  attached,  is 
also  composed. 

There  are  both  longitudinal  and  circular  fibres  in  the  media. 
These  close  around  the  stump  of  the  vessel,  and  become  interlaced. 
There  are  very  few  elastic  fibres,  and  the  appearance  of  an  elastic 
lamina  is  seen  only  at  one  or  two  points. 

The  clot  is  penetrated  by  columnar  masses  of  embryonic  tissue 
which  spring  from  the  inner  walls:  the  intima  appears  as  a  layer  of 
hyaline  connective  tissue  containing  spindle-shaped  cells,  and  is 
separated  from  the  media  by  a  very  thin  and  interrupted  elastic 
membrane. 

Cross  sections  bring  out  the  circular  fibres:  in  those  near  the 
distal  end,  the  cells  are  undergoing  a  hyaline  degeneration  which 
pervades  the  whole  wall.  The  lumen  is  much  reduced  in  size,  and 
has  a  stellate  outline.  The  line  of  separation  between  the  inner 
coats  is  ill  defined  low  down,  but  higher  up  the  elastic  membrane 
is  found,  as  are  also  elastic  fibres  between  the  bundles  of  cells. 
Granulations  are  seen  penetrating  the  clot,  and  deep  folds  of  the 
walls  also  project  into  it,  each  helping  to  obliterate  the  lumen. 

Near  the  origin  of  the  vessel  cross  sections  show  a  contraction 
of  the  lumen,  throwing  the  walls  into  irregular  folds,  which  are 
bridged  over  by  a  slight  growth  of  young  connective  tissue  on  their 
inner  surface.  Where  a  branch  is  given  off,  the  typical  lamina  of 
the  latter  may  be  traced  directly  into  the  tortuous  and  interrupted 
elastic  membrane  of  the  hypogastric  artery. 

Remarks. — The  ends  of  the  vessel,  for  an  inch  or  more  from  the 
umbilicus,  show  signs  of  a  hyaline  degeneration.     One  quarter  of  this 


132  TJic  Ligature  of  Artci'ics. 

portion  has  already  been  converted  into  a  cord.  The  lumen  is  greatly 
narrowed  for  a  considerable  distance  beyond  by  a  contraction  of  the 
media,  and  by  a  growth  from  the  walls  of  the  vessel  into  the  throm- 
bus, which  is  in  process  of  disintegration.  Near  the  origin  we  see 
the  beginning  of  a  growth  which  is  destined  to  diminish  the  calibre 
of  the  vessel  at  this  point. 

REMAINS   OF    THE    HYPOGASTRIC   ARTERY. 
Adult. 

The  specimen  included  a  portion  of  the  internal  iliac,  the  superior 
vesical  artery,  and  the  ligament  to  within  about  three  inches  of  the 
umbilicus. 

One  of  the  vessels  was  laid  open  from  its  origin  in  the  internal 
iliac  for  about  one  third  of  its  length,  when  the  lumen  became  too 
narrow  for  the  microscope-scissors  to  follow  it  farther.  The  walls 
were  found  to  be  much  thicker  than  in  vessels  of  this  size  elsewhere. 
The  lumen  could  be  traced  by  the  naked  eye  for  some  distance 
farther  by  cutting  open  the  specimen  with  a  sharp  razor.  Beyond 
this  point,  the  cord  appeared  to  consist  of  bundles  of  fibres  sur- 
rounding a  centre  of  denser  and  whiter  material,  which  could  be 
traced  to  the  end  of  the  specimen;  that  is,  to  within  about  three 
inches  of  the  unbilicus.  The  companion  vessel  was  divided  into 
nine  portions  for  microscopical  examination,  cross  sections  being 
made  of  each  portion,  except  the  first,  which  included  the  point  of 
junction  of  the  superior  vesical  with  the  iliac  artery,  and  was  cut 
longitudinally. 

At  the  point  of  origin  of  the  vesical  artery  there  is  a  thickening 
of  the  intima  of  the  internal  iliac,  which  could  be  traced  to  the  end 
of  the  specimen,  about  one  quarter  of  an  inch,  in  the  direction  of 
the  origin  of  the  iliac.  This  thickening,  which  consists  of  circu- 
larly and  longitudinally  disposed  spindle-shaped  cells  in  a  hyaline 
matrix,  appears  to  originate  between  two  layers  of  the  elastic  lamina. 
The  internal  lamina  accompanies  the  new  tissue  into  the  vesical 
artery  to  its  most  distant  portions,  and  here,  at  all  events,  appears 
as  a  new  formed  membrane;  a  membrane  which  is  not  found  in  foetal 
life.  It  is  at  first  thrown  into  deep  transverse  folds,  and  becomes 
more  widely  separated  from  the  middle  coat  in  the  vesical  artery. 

Cross  sections  in  the  second  portion  of  the  specimen  show  the 
following  layers  in  the  walls  of  the  vessel  (Fig.  32).  On  the  inner 
surface  is  the  delicate  layer  of  the  endothelium,  beneath  which  is 
the  elastic  lamina,  a  thick  but  not  highly  refracting  membrane,  such 


The  Closure  of  the  Fci'tal  Vessels.  133 

as  is  usually  seen  in  other  vessels  of  this  size.  It  is  slightly  undu- 
lating in  character,  and,  in  this  respect,  is  in  contrast  with  the  deep 
folds  into  which  that  membrane  is  usually  thrown  in  contracted 
vessels.  Outside  of  this  lamina  is  a  narrow  layer  of  circular  mus- 
cular fibres,  on  the  outer  borders  of  which  are  found  here  and  there 
a  few  longitudinal  cells.  Next  comes  the  imperfectly  developed 
lamina  belonging  originally  to  the  hypogastric  artery.  This  is  thinner 
and  not  a  continuous  membrane,  but  refracts  the  light  more  power- 
fully than  the  inner  membrane,  and  is  thrown  into  deep  folds.  Out- 
side of  this  lamina  is  the  old  media  of  the  hypogastric  artery,  con- 
sisting of  cells  disposed  circularly,  obliquely,  and  longitudinally. 
This  coat  varies  greatly  in  thickness  at  different  points,  and  frequently 
on  different  sides  of  the  vessel  at  the  same  point.  Outside  of  all  lies 
the  adventitia.  These  various  layers  make  up  a  wall  thick  out  of 
all  proportion  to  the  lumen  of  the  vessel. 

In  the  third  portion  examined  the  conditions  described  remain 
unchanged;  but  in  the  fourth  portion  the  lumen  grows  rapidly  nar- 
rower, the  outline  between  the  double  walls  becoming  indistinct  and 
difficult  to  trace.  The  course  of  the  vessel  is  now  tortuous,  and 
soon  loses  itself  in  the  tissues  of  the  ligament.  A  more  careful  ex- 
amination of  sections  at  this  point,  however,  shows  a  slight  cleft  in 
the  fibres,  of  irregular  outline,  surrounded  by  a  denser  tissue  than 
prevails  in  other  portions  of  the  section,  containing  remains  of  the 
elastic  fibres  and  membrane.  These  remains  of  the  vessel  can  be 
traced  through  the  fifth,  sixth,  and  seventh  portions,  becoming 
gradually  fainter,  and  are  with  difificulty  found  in  many  sections. 

In  the  eighth  and  part  of  the  ninth  portion, where  the  cord  becomes 
more  compact,  and  the  tissue  takes  coloring  matter  better,  it  is  more 
distinctly  seen  again,  and,  in  the  central  cleft,  a  capillary  vessel  can 
be  traced  for  a  short  distance:  finally,  in  the  most  distal  sections  it 
is  not  possible  to  say  whether  any  traces  of  the  vessel  can  be  found, 

Reniarks. — Traces  of  the  old  vessel  can  be  followed  to  within 
three  inches  of  the  umbilicus.  We  have  evidence  of  contraction 
of  the  outer  walls,  followed  by  a  development  of  new  tissue  inside 
the  vessel.  In  this  respect,  and  in  its  gradual  diminution  in  size  to 
an  arteriole  and  capillary,  it  closely  resembles  the  artery  of  an  am- 
putation stump. 

HYPOGASTRIC  ARTERY. 
Monkey. 
Both  vessels  were  removed,  but  the  vessel  of  one  side  onl}-  was 


134  J^li-<-^  Ligatjirc  of  Artci-ics. 

examined:  it  was  cut  into  four  portions,  cross  sections  being  made 
of  eacli  portion.  Near  the  origin  of  the  artery  a  growth  of  new 
tissue  is  found  on  the  inner  surface  of  its  walls,  between  the  endo- 
thelium and  the  elastic  lamina.  It  consists  of  spindle-shaped  cells 
in  two  layers,  the  inner  arranged  circularly;  the  outer  running 
parallel  to  the  axis  of  the  vessel.  This  growth  gradually  increases 
in  quantity  as  we  approach  the  distal  end  of  the  vessel;  and,  on 
arriving  at  about  the  middle  portion,  we  find  the  lumen  diminished 
to  one  half  of  its  calibre  by  the  new  growth;  the  remaining  lumen 
seeming  to  owe  its  existence  to  the  presence  of  a  newly  formed  vessel 
occupying  the  centre  of  the  new  tissue,  (Fig.  34),  and  possessing 
walls  of  its  own  independent  of  those  which  pre-existed. 

We  find  here  a  delicate  endothelium  surrounded  by  a  layer  of 
muscular  fil)re,  no  elastic  lamina  intervening  between  the  two  layers. 
Around  this  central  vessel  is  what  may  be  regarded  as  the  obliterat- 
ing growth,  composed  of  connective  tissue,  and,  possibly,  some 
longitudinal  muscular  cells. 

The  old  elastic  lamina,  which  is  a  very  thick  and  glistening 
membrane,  seen  throughout  the  whole  course  of  the  vessel,  comes 
out  in  strong  relief  outside  of  the  new  tissue,  but  is  generally  found 
ruptured  at  one  or  two  points.  It  is  thrown  into  unusually  deep 
folds.  Outside  of  it  the  cells  of  the  media  are  seen,  arranged  cir- 
cularly, and  differing  from  the  media  in  man,  where  longitudinal 
fibres  are  also  found.  There  is  nothing  worthy  of  mention  in  the 
appearance  of  the  adventitia. 

Near  the  terminal  portions  the  vessel  appears  much  contracted, 
becomes  tortuous,  and  the  various  layers  are  less  easily  distinguished. 
Finally,  we  come  to  sections  where  arterioles  and  capillaries  only 
are  found. 

Remarks. — The  changes  observed  in  the  interior  of  this  vessel 
closely  resemble  those  seen  in  obliterating  endarteritis.  The  perfec- 
tion of  the  staining  process,  and  the  clearness  of  the  cell-structure, 
show  the  muscular  character  of  a  portion  of  the  obliterating  tissue. 
No  newly  formed  elastic  lamina  is  seen  in  this  specimen.  The  vessel 
is,  however,  very  much  smaller  than  that  taken  from  the  human 
subject. 

On  laying  open  the  hypogastric  artery  of  the  newly  born  child, 
a  thrombus  is  found,  extending  from  the  point  of  obliteration  at  the 
umbilicus  through  about  one  third  of  its  extent.  This  was  the  case 
in  all  specimens  examined.     Considering  the  very  moderate  amount 


IJie  Closure  of  the  Foetal   J'essels.  135 

of  traumatism  exerted  upon  this  vessel,  the  presence  of  a  thrombus 
is  of  special  interest  in  its  bearing  upon  the  question  of  the  forma- 
tion of  a  thrombus.  It  is  not  probable  that  the  clot  takes  its  origin 
in  the  extra-umbilical  portion  of  the  vessel  after  the  ligature  has 
been  applied,  for  this  portion  contracts  rapidly,  and  its  lumen  is 
obliterated  very  shortly  after  birth.  The  very  moderate  amount  of 
inflammation  produced  at  the  umbilicus  could  hardly  suffice  to  pro- 
duce a  clot  of  such  size;  for,  as  a  rule,  healing  takes  place  without 
the  formation  of  pus.  So  far,  therefore,  as  these  observations  go, 
no  very  large  number  of  specimens  having  been  examined,  they  fail 
td  support  the  theory  of  the  traumatic  origin  of  the  thrombus. 

The  hypogastric  artery  presents  certain  peculiarities  which  distin- 
guish it  from  other  arteries.  The  most  striking  of  these  is  the  presence 
of  a  large  amount  of  longitudinal  muscular  fibre,  in  which  respect  it 
bears  a  resemblance  to  the  structure  of  the  ductus.  It  has  another 
peculiarit)'',  also,  in  common  with  that  vessel,  consisting  in  the  ab- 
sence of  a  well-defined  outline  to  the  inner  wall  of  the  media,  which 
a  well-formed  lamina  elastica  gives.  Elastic  tissue  is  found  at  this 
point,  but  the  membranes  are  thin,  not  always  continuous,  and  some- 
times hard  to  find.  Near  the  distal  end  of  the  vessel  there  is  little 
to  be  seen  of  any  such  structure. 

When  the  placental  circulation  ceases,  a  marked  contraction 
takes  place  throughout  the  greater  part  of  the  vessel,  and  its  most 
distal  portion  is  filled  with  a  thrombus.  While  the  healing  of  the 
umbilical  cicatrix  is  taking  place,  the  distal  end  of  the  artery  is 
undergoing  hyaline  degeneration  which  pervades  its  whole  thickness. 
A  few  weeks  after  birth  we  see  that  portion  where  the  two  vessels  lie 
in  contact,  reduced  to  a  cord  of  gelatinous  tissue  in  which  all  traces 
of  the  vessel  have  disappeared.  This  change  extends,  and,  at  this 
period,  has  already  involved  the  walls  of  each  artery  for  perhaps  one 
half  to  three  quarters  of  an  inch  beyond  this  point,  indicating  evi- 
dently a  destruction  of  the  vessel,  for  a  considerable  distance  from 
its  distal  end.  This  view  is  borne  out  by  the  examination  of  the 
fibrous  cord,  which  attaches  the  superior  vesical  artery  to  the  umbi- 
licus. Here,  traces  of  the  walls  of  the  vessels  are  still  seen,  chiefly 
fragments  of  elastic,  and  dense,  fibrous  tissue.  Baumgarten's  view, 
that  the  vessel  is  preserved  entire,  but  appears  smaller  owing  to  the 
growth  of  the  body,  is  thus  disproved,  and  the  possibility  of  the 
destruction  of  a  considerable  fragment  of  the  hypogastric  artery 
is  clearly  established. 

In  the  early   days  of  life  but  little  change  is  seen  in  the  interior 


136  The  Ligature  of  Arteries. 

of  the  vessel;  a  slight  proliferation  of  the  cells  of  the  intima  is 
noticed  near  the  apex  of  the  thrombus,  but  not  elsewhere.  By  the 
second  month,  however,  a  distinct  growth  of  tissue  may  be  observed 
throughout  the  entire  length  of  the  inner  wall.  The  coats  have 
contracted,  and  the  inner  surface  is  thrown  into  deep  folds  which 
are  bridged  over  by  a  growth  of  young  cells,  lying  imbedded  in  a 
hyaline,  intercelullar  substance.  This  tissue  fills  out  the  irregu- 
larities, and,  in  cross  section,  the  lumen  noiv  presents  a  smooth 
contour.  In  the  region  occupied  by  the  thrombus  the  growth  of  new 
tissue  is  most  active;  granulation-like  masses  intersect  the  clot,  and 
are  rapidly  obliterating  the  lumen.  At  this  period  we  are  able  to 
establish  the  fact  of  a  general  contraction  of  the  vessel  throughout 
its  whole  extent,  a  still  further  narrowing  of  the  lumen  in  its  proxi- 
mal portion,  and  the  beginning  of  a  destructive  process  at  its  terminal 
portion. 

In  adult  life,  a  cross  section  taken  through  the  walls  near  the 
proximal  end,  shows  the  old  wall  of  the  vessel  much  contracted, 
as  indicated  by  the  deep  folds  of  the  elastic  lamina  (f'ig.32).  With- 
in exists  a  tissue  evidently  formed  subsequently  to  this  contraction, 
for  it  does  not  appear  to  have  been  affected  by  it.  This  tissue  has 
now  developed  into  a  newly  formed  lamina  elastica,  surrounded  by  a 
new  layer  of  muscular  cells.  Although  the  lumen  is  quite  small, 
the  walls  of  the  vessels  are  of  considerable  thickness.  Tracing  the 
vessel  to  its  extremity,  we  find  the  lumen  constantly  diminishing 
in  size,  the  newly  formed  internal  coat  becoming  less  distinct,  until 
the  structures  examined  consist  of  a  cord  of  fibrous  tissue  in  which 
a  tortuous  arteriole  finally  breaks  up  into  smaller  vessels  which  are 
not  to  be  distinguished  from  capillaries.  Beyond  this  point  we  see 
only  a  fibrous  cord,  in  the  centre  of  which  is  some  denser,  more 
opaque  tissue  intermingled  with  traces  of  an  elastic  membrane. 

The  series  of  changes  which  has  taken  place  since  birth  in  this 
vessel  may  be  summarized  as  follows:  a  contraction  followed  by  a 
still  greater  diminution  of  the  calibre  by  an  obliterating  growth  of 
the  proximal  portion,  and  a  complete  destruction  of  the  terminal 
portion,  in  extent  amounting  to  about  one  third  of  the  original 
vessel.  Thoma's  assumption  that  a  portion  of  the  newly  formed 
tissue  is  of  a  muscular  character  is  fully  confirmed.  That  this 
tissue  is,  however,  developed  from  the  intima,  as  he  asserts,  can 
hardly  be  accepted,  the  imperfect  separation  of  the  intima  from 
the  media  making  it  quite  possible  for  that  layer  to  have  participated 
in  the  growth.     This  view  is  in  a  measure  confirmed  by  the  investiga- 


TJic  Closure  of  the  Fatal  J'esse/s.  137 

tions  quoted  above,  bearing  upon  this  point.  Baumgarten's  state- 
ment, that  the  extreme  end  of  the  vessel  is  closed  with  fibrous  tissue 
is  not  borne  out,  the  vessel  gradually  diminishing  in  size  to  an 
arteriole  which,  in  its  turn,  ends  in  capillaries. 

Cross  sections  of  the  artery  taken  from  the  monkey  show  the 
newly  formed  muscular  layer  with  great  distinctness.  A  new  lamina 
does  not  exist,  but  the  old  wall  contains  a  strong  lamina  thrown  into 
deep  folds  (Fig.  34).  In  this  respect,  it  corresponds  with  the  arte- 
riole seen  in  the  obliterating  tissue  of  the  tibial  artery  (Fig.  35), 
where  the  lamina  is  also  preserved  in  the  old  vessel-wall,  but  absent  in 
the  new  wall,  differing,  however,  from  the  arrangement  in  the  hypo- 
gastric, in  which  the  old  lamina  is  not  a  well-developed  membrane. 

It  is  also  worth  noting  that  the  walls,  both  of  the  obliterated 
tibial  artery  and  femoral,  have  undergone  calcification  (Figs.  35  and 
;^2,).  Such  a  change  was  not  observed  in  any  of  the  hypogastric 
arteries  of  adults  which  were  examined,  but  was  almost  invariably 
found  in  the  ligamentum  arteriosum.  The  observation  suggests  the 
view  that  this  degenerative  change  may  be  the  result  of  cessation  of 
function  of  the  vessel-wall,  rather  than  the  sign  of  disease  which 
has  led  to  obliteration  of  the  vessel.  If  this  be  the  true  explanation 
of  changes  in  the  walls  of  the  vessels,  the  subjects  of  endarteritis 
obliterans,  new  light  is  thrown  upon  the  etiology  of  that  disease, 
which  should  no  longer  be  regarded  as  originating  in  an  inflamma- 
tion of  the  coats  of  the  vessel.  Such  changes  as  are  observed  are 
due  more  probably  to  a  participation  of  these  vessels  in  a  formative 
process  made  necessar)^  in  consequence  of  diminished  blood  supply, 
and  their  subsequent  degeneration  from  lack  of  use.  A  study  of 
the  changes  observed  in  the  hypogastric  artery  after  birth  brings 
out  a  close  resemblance  to  the  changes  seen  in  arteries  after  amputa- 
tion. In  the  earliest  period  we  find  contraction  of  the  vessels  in 
their  entire  extent,  with  occlusion  of  the  distal  portions  by  thrombosis. 
Later,  a  growth  from  the  inner  wall  is  observed  in  each  case,  and 
finally  new  blood-channels  are  established  within  the  old,  the  newly 
formed  vessels  being  accurately  adapted  to  the  decreased  blood 
supply.  In  the  hypogastric  artery  there  is  the  most  satisfactory  proof 
of  the  formation  of  new  muscular  fibre,  which,  taken  with  the  obser- 
vations in  amputation  stumps,  shows  that,  even  in  this  form  of 
healing  after  ligature,  new  muscular  fibre  may  be  produced. 


CHAPTER  V. 

SUMMARY. 

The  materials  collected  by  these  experiments  and  investigations 
are,  we  think,  sufficient  to  enable  us  to  draw  a  few  conclusions  as  to 
the  nature  of  the  process  of  repair  in  arteries  after  ligature,  and  to 
recognize  some  of  its  more  important  phases.  One  of  the  most 
interesting  facts  thus  established  is  the  duration  of  the  process, 
which  greatly  exceeds  that  usually  ascribed  to  it.  The  period  of 
time  from  the  moment  of  ligature  to  the  development  of  the  final 
scar,  varies  considerably  with  different  vessels.  For  those  of  large 
size  it  may  be  said  to  range  from  three  to  six  months.  In  some 
cases  a  cicatrix  may  be  formed  at  an  earlier  date,  but  in  no  instance 
has  it  been  possible  to  find  a  specimen  in  which  all  the  changes  of 
the  series  have  been  fully  completed  before  the  shorter  period. 

Another  feature  brought  out  quite  prominently  is  the  complicated 
nature  of  the  process.  The  walls  of  a  vessel  of  the  first  class  are  com- 
posed of  structures  of  great  strength  and  density,  the  elastic  tissue, 
of  which  they  are  largely  constituted,  being  one  of  the  strongest  and 
toughest  tissues  in  the  body.  The  vasa  vasorum  are  minute  vessels, 
and  ramify  in  a  tissue  which  is,  within  certain  limits,  quite  unyielding 
to  pathological  influences.  The  conditions  favorable  for  a  rapid  series 
of  changes  dependent  upon  inflammatory  and  reparative  processes, 
such  as  is  found  in  the  more  loosely  woven  connective  tissues,  do 
not  exist  here,  and  nature  is  consequently  obliged  to  resort  to  the 
expedient  with  which  we  are  most  familiar  in  connection  with  the 
process  of  repair  in  bone,  of  supplying  provisional  structures  which 
seal  the  vessel  while  the  coats  gradually  elaborate  those  elements 
which  are  to  form  part  of  the  future  cicatrix. 

Many  of  the  specimens  preserved  in  museums  have  the  appear- 
ance of  having  united  by  first  intention.  Those  illustrating  the  pre- 
cise moment  when  the  adventitia  has  been  absorbed  by  granulation 
tissue,  and  the  ligature  lies  imbedded  in  the  tissue,  separated  from 
the  two  ends  of  the  vessel  (Fig.  I,  Frontispiece),  suggest  strongly  such 
a  mode  of  union.  Some  writers  have  advocated  the  possibility  of 
such  an  occurrence,  but  there  are  no  facts  in  the  materials  before  us 
which  authorize  any  such  conclusions. 


I 


I 


Sunn  nary.  139 

Finally,  the  nature  of  the  cicatrix  observed  in  the  foregoing 
specimens  differs  essentially  from  that  usually  ascribed  to  it.  No 
question  in  surgical  pathology  has  been  more  vigorously  debated 
than  that  which  refers  to  the  part  played  by  different  elements  in 
the  process  of  repair  in  arteries.  On  one  ponit  there  seems  to  have 
existed  a  singular  unanimity,  it  being  universally  conceded  that  the 
muscular  coat  did  not  participate  in  the  process.  The  experiments 
here  recorded  seem  to  show  pretty  conclusively  that  the  muscular 
cell  is  a  prominent  and  essential  feature  of  the  arterial  cicatrix. 

The  process  of  repair  may,  for  the  purpose  of  study,  be  divided 
into  three  principal  stages.  In  the  first  are  included  those  changes 
which  occur  immediately  after  the  application  of  the  ligature,  and  dur- 
ing the  period  in  which  the  walls  of  the  vessel  are  gradually  separated 
from  it.  The  second  stage  embraces  the  period  of  development  of 
the  provisional  structures,  or,  if  we  prefer  to  use  the  term,  the  ex- 
ternal and  internal  callus.  During  the  third  stage  there  is  a  process 
of  differentiation  of  the  elements  of  which  the  internal  callus  is 
composed,  and  a  gradual  absorption  of  the  provisional  tissues  until 
the  period  of  final  cicatrization  is  reached. 

The  application  of  a  strong  ligature  to  the  trunk  of  an  artery 
usually  ruptures  the  inner  and  middle  coats;  this  is  always  the  case 
in  dogs,  and  the  human  specimens  examined  showed  no  essential 
difference.  The  outer  coat  is  composed  of  elastic  tissue  which  is 
collected  into  a  dense  and  singularly  strong  bundle  of  fibres,  which 
protects  the  injured  walls  and  prevents  hemorrhage.  Some  idea 
of  the  powers  of  resistance  of  this  fascia-like  tissue  may  be  gathered 
from  the  experiments  of  Ogston.  The  ruptured  inner  walls  are 
slightly  inverted  so  as  to  form  a  V-shaped  wound  when  seen  in 
section  (Figs,  i  and  2),  or  a  cone  with  its  base  presenting  towards 
the  lumen  of  the  vessel.  There  is  no  valve-like  incurvation  of 
the  walls,  as  is  said  to  exist  after  torsion.  The  proximal  end,  if 
the  thrombus  be  large,  assumes  an  ampulla-like  shape,  as  described 
by  Bryant.  This  is  probably  due,  not  to  a  dilatation  of  the  vessel, 
but  rather  to  an  inability  of  the  vessel  to  contract,  owing  to  the  size 
of  the  thrombus,  which  is  largest  at  its  base.  The  walls,  however, 
are  stretched  and  thin,  compared  with  other  points,  indicating  that 
the  vessel  here  is  of  full  size.  The  distal  extremity  is  more  uniform 
in  calibre,  and  contracted  as  much  at  its  end  as  elsewhere,  or  nearly  so. 

The  size  and  appearance  of  the  thrombus  differs  greatly  in 
different  specimens.  In  ligatures  in  continuity  in  man,  of  tlie 
period  during  which  the  thrombus  is  found,  it  was  a  marked   feature 


140  The  Ligature  of  Arteries. 

of  the  preparation.  It  was  both  "  red  "  and  "  stratified  "  in  appear- 
ance. In  all  cases  it  extended  up  to  the  first  branch  of  consider- 
able size.  Usually  it  was  firmly  adherent  at  its  base  to  the  walls  of 
the  vessel  on  the  proximal  side,  and,  as  a  rule,  the  distal  thrombus 
became  separated  from  the  specimen  in  course  of  preparation.  The 
proximal  thrombus  was  not  only  wider,  but  also  longer  than  the 
distal  thrombus  in  all  these  specimens.  In  the  amputation  stumps  the 
vessels,  as  far  as  removed,  were  in  most  cases  filled  with  thrombi. 
All  the  specimens  examined  were  taken  from  septic  wounds. 

In  dogs  there  was  a  great  divergence  in  size.  In  some  cases  the 
entire  trunk  was  filled  with  clot,  in  others  the  thrombus  was  less  than 
two  millimetres  in  length.  It  was  invariably  a  "  red  "  thrombus,  but 
was  not  always  stratified.  In  the  horse  the  amount  of  thrombus  also 
varied  greatly.  In  the  specimen  shown  in  the  Frontispiece  the  prox- 
imal thrombus  is  a  white  or  "decolorized"  thrombus,  the  two 
thrombi  being  about  equal  in  size. 

The  series  of  ligatures  made  under  antiseptic  precautions  pro- 
duced thrombi  of  greatly  diminished  size,  the  proximal  thrombus 
being  about  one  and  one-half  millimetres  in  length  in  the  smaller 
specimens  observed,  the  distal  being  slightly  smaller.  Such  speci- 
mens were  taken  from  vessels  about  three  and  one-half  millimetres 
in  internal  circumference.  In  no  case  was  the  thrombus  absent. 
When  the  thrombus  was  of  the  size  just  mentioned  it  was  polypoid 
in  shape,  and  was  attached  by  its  pedicle  to  one  of  the  projecting 
edges  of  the  media. 

The  marked  contrast  between  thrDmbi  in  wounds  where  antiseptic 
precautions  were  observed  and  union  by  first  intention  was  obtained, 
and  those  in  which  no  precautions  were  taken,  was  such  as  to  leave  no 
doubt  as  to  the  influence  of  septic  products  upon  the  process  of 
coagulation.  In  all  cases  the  amount  of  bruising  of  the  vessel-wall 
was  about  the  same  as  has  been  described.  In  certain  attempts  to 
close  the  vessel  without  rupturing  the  internal  wall,  it  was  found  that 
the  lumen  had  not  lieen  fully  obstructed,  and,  at  the  same  time,  that 
the  walls  had  been  bruised  to  a  certain  extent,  so  that,  whenever  the 
ligature  was  drawn  tightly  enough  to  obstruct  the  flow  of  blood,  there 
was  considerable  bruising  of  the  media.  Although  in  two  cases 
examined,  the  opening  through  the  ligature  had  been  extremely 
small,  and  although  there  was  considerable,  but  not  continuous, 
bruising  of  the  media  around  the  vessel,  no  trace  of  thrombus  was 
observed  in  either  case.  The  experiments  were  made  on  the  carotids 
of  large  dogs,  where  the  current  was  strong. 


Suimnary.  141 

The  experiments  of  Baumgarten,  Senn,  and  others  tend  to  show 
that  the  extent  of  traumatism  is  the  most  important  factor  in  the 
production  of  the  thrombus,  the  exciting  cause  being  probably  the 
presence  of  some  ferment-N'ielding  substances.  The  experiments 
with  antiseptic  precautions,  reported  above,  are  confirmatory  of  such 
views.  In  some  of  the  preparations,  taken  from  extremely  septic 
amputation  wounds,  the  thrombus  was  exceedingly  small;  on  the 
other  hand,  a  clot  of  considerable  size  was  always  found  in  the  hypo- 
gastric artery  of  infants  newly  born,  filling  nearly  a  third  of  the 
vessel,  and,  in  one  case,  a  thrombus  of  considerable  thickness  was 
found  to  fill  about  two-thirds  of  the  obliterated  ductus  arteriosus. 
Certainly  in  the  latter  case  there  could  not  have  existed  a  local  sepsis 
or  traumatism.  In  none  of  the  experiments  performed  was  there  an 
entire  absence  of  the  thrombus.  In  one  or  two  experiments,  made 
with  the  double  ligature,  the  blood  did  not  remain  fluid  between  the 
ligatures,  as  has  been  reported  by  a  number  of  observers,  although 
the  wounds  healed  by  first  intention.  Baumgarten  maintains  that 
an  artery  can  be  tied  without  the  formation  of  a  thrombus.  In  some 
of  the  experiments,  recorded  above,  the  thrombus  was  about  the 
size  of  a  mustard-seed,  and  could  easily  have  been  overlooked,  or 
might  accidentally  have  become  detached  during  the  preparation  of  the 
specimen.  We  must  conclude,  therefore,  that  although  traumatism 
or  sepsis  may  be  the  chief  factors  in  the  production  of  the  thrombus 
after  ligature,  the  size  of  the  thrombus  does  not  depend  entirely 
upon  the  extent  or  degree  of  these  conditions,  (jranular  masses  or 
"  blood-plaques "  were  frequently  observed  in  experiments  upon 
dogs.     (Figs  6,  7,  10.) 

The  rapidity  of  the  formation  of  the  thrombus  was  a  question 
considered  during  experimentation.  In  the  femoral  artery  of  the  dog, 
ligatured  in  continuity,  there  was  no  thrombus  one  hour  after  the 
ligature  had  been  applied.  In  the  brachial  artery  of  man,  which  had 
been  lacerated,  there  was  a  firm  homogeneous  clot  two  hours  after 
the  injury  had  been  received  (Fig  4).  In  the  femoral  of  a  man, 
whose  thigh  had  been  amputated  twenty  hours  before,  there  was 
already  a  well- formed  laminated  clot.  In  vessels  in  which  the 
hemorrhage  has  ceased  spontaneously,  a  thrombus  will  probably 
always  be  found  immediately  after  the  bleeding  has  stopped.  After 
ligature  it  is  probable  that  an  hour  or  more  may  elapse  before  the 
thrombus  has  become  perceptible  to  the  naked  eye.  That  a  human 
artery  can  be  tied  and  heal  without  the  formation  of  a  thrombus,  is 
a  possibility  which  the  data  at  present  in  our  possession  do  not  au- 


142  The  Ligatiirc  of  Arteries. 

thorize  us  to  concede.  The  thrombus  protects  the  wound  in  the 
vessel.  This  is  evident  when  the  inflammation  is  severe  and  sup- 
puration takes  place.  Its  period  of  greatest  usefulness  begins  when 
the  walls  of  the  vessel  are  retracting,  and  granulations  are  growing 
into  it.  The  thrombus  then  serves  as  a  good  culture  medium  for 
the  granulation  cells  in  its  deeper  portions,  while  its  extremity  forms 
a  protecting  scab. 

Soon  after  the  application  of  the  ligature  a  collection  of  wander- 
ing cells  takes  place  in  its  neighborhood,  and  it  is  presently  imbedded 
in  a  mass  of  granulation  tissue  which  surrounds  the  ends  of  the  vessel. 
At  an  early  day  some  of  these  cells  may  be  seen  in  the  meshes  of 
the  adventitia,  where  the  fibres  are  not  too  closely  packed  together, 
and  in  the  outer  layers  of  the  media.  At  the  base  of  the  proximal 
thrombus,  which  is  firmly  attached  to  the  wall  of  the  vessel,  are  also 
numbers  of  white  blood  corpuscles,  which  are  most  numerous  in 
and  about  the  little  V-shaped  cleft  in  the  wall  formed  by  the  rupture 
at  the  point  of  ligature.  The  appearances  are  suggestive  of  an 
immigration  of  wandering  cells,  but  usually  these  cells  have  only 
penetrated  the  outer  walls  of  the  vessel,  and  the  collection  of  cells 
seen  within  the  vessel  is  probably  due  to  the  accumulation  of  white 
corpuscles  at  the  bruised  spot  during  the  process  of  coagulation. 
Occasionally  (Fig.  i)  we  may  see,  however,  an  invasion  of  the  walls 
by  wandering  cells  from  without,  and  it  is  probable  that  a  limited 
number  of  wandering  cells  find  their  way  into  the  interior  of  the 
vessel  in  every  case,  during  the  first  week. 

In  the  interior  of  the  vessel  we  find  no  marked  activity  of  the 
cell-elements  during  this  period.  In  many  specimens  there  appears 
to  be  absolutely  no  change  whatever  in  the  endothelium.  In  others, 
and  probably  in  the  majority  of  cases,  a  proliferation  of  these  cells 
maybe  observed,  particularly  at  the  distal  end  (Fig.  3).  A  somewhat 
more  active  growth  may  be  found  at  the  apex  of  the  thrombus,  where 
the  vessel-walls  have  contracted  closely  around  it.  Here  a  distinct 
thickening  of  the  intima  may  be  seen,  not  only  in  dogs  but  also  in 
man, and  a  number  of  spindle-shaped  cells  can  be  found  attached  to  the 
surface  of  the  clot.  Wherever,  at  some  point  more  or  less  remote 
from  the  ligature,  ruptures  have  occurred  in  the  lamina  elastica, 
and  these  are  common,  a  growth  of  cells  can  be  observed  projecting 
from  the  media  for  a  short  distance  into  the  clot  (Fig.  6).  The 
total  amount  of  cell-growth  produced  from  these  various  sources  is 
insignificant,  and  its  chief  purpose  seems  to  be  to  attach  the  throm- 
bus more  firmly  to  the  inner  walls  of  the  vessel,  so  that,  when  the 


Sjimniary.  143 

walls  escape  from  the  ligature,  and  expansion  takes  place,  its  con- 
nection with  the  vessel-wall  shall  not  be  seriously  affected.  A  more 
prominent  place  in  the  process  of  repair  cannot  be  given  either  to 
the  endothelium  or  to  the  wandering  cells.  Later,  a  growth  from 
the  endothelium  probably  supplies  a  coating  to  the  new  vascular 
spaces  in  the  cicatrix,  but  an  extended  series  of  observation  fails  to 
show  that  these  cells  play  the  principle  role  in  the  formation  of  the 
cicatrix,  as  is  maintained  at  the  present  time  by  a  large  number  of 
histologists. 

The  special  experiments  with  double  ligature,  following  the 
method  of  previous  observers,  in  order  to  test  the  activity  of  the 
wandering  cells  or  of  the  endothelium,  failed  to  show  that  either  of 
these  groups  of  cells  were  the  agents  by  which  the  segments  became 
obliterated,  but  showed  that  granulations  eventually  grew  in  at  each 
end,  and  filled  this  portion  of  the  vessel.  A  slight  proliferation  of 
the  endothelium  was  occasionally  observed,  but  in  other  cases  it 
was  absent  entirely,  and  in  no  case  did  the  cell-growth  amount  to 
a  perceptible  thickening  of  the  intima.  In  severe  forms  of  inflam- 
mation it  was  found  possible  for  a  wandering  cell  to  enter  the  seg- 
ment cut  off  by  the  ligatures  before  the  ends  had  admitted  granula- 
tions. 

In  some  specimens  a  slight  growth  of  endothelium  was  seen 
covering  the  bruise  in  the  media,  when  the  clot  was  small  and  per- 
mitted a  view  of  the  part.  In  the  temporary  ligature,  the  wound 
in  the  media  was  found,  at  the  end  of  the  first  week,  covered  by 
a  thin  film  of  endothelium,  and  active  cell-proliferation  was  found 
also  in  the  media. 

In  none  of  these  various  experiments  was  there  any  evidence  to 
show  that  the  cell-growth  in  the  interior  of  vessels  during  cicatriza- 
tion was  supplied  from  the  intima  alone. 

Outside  the  vessel  the  granulation  tissue  accumulates  to  such  an 
extent  as  to  cover  in  the  ligature  and  the  ends  of  the  vessel,  form- 
ing a  spindle-shaped  mass,  thickest  over  the  ligature,  and  tapering 
off  _above  and  below.  It  varies  greatly  in  size  according  to  the 
amount  of  inflammation  produced.  In  healing  by  first  intention  it 
is,  however,  a  well-marked  structure,  and  is  something  more  than  a 
mere  ring  of  new  tissue  enclosing  the  ligature,  for,  even  in  these 
cases,  it  extends  up  and  down  the  vessel  for  a  short  distance.  In 
large  vessels,  it  forms  a  callus  of  considerable  size,  even  when  the 
healing  of  the  wound  has  been  rapid.  This  is  shown  in  the  vessels 
of  the  horse  (Frontispiece),  and  also  in  those  of  man,  notably  in  the 


144  ^'^^^  Ligature  of  Arteries. 

subclavian  artery,  and  in  a  specimen  of  the  carotid  artery  prepared 
in  such  a  way  as  to  show  the  callus. 

While  the  callus  has  been  enlarging,  its  cells  have  infiltrated  the 
outer  fibres  of  the  adventitia,  and  they  gradually  disintegrate  and 
absorb  the  bundle  of  fibres  held  by  the  ligature,  which  now  lies  en- 
closed by  a  wall  of  granulation  cells  on  all  sides.  The  walls  of  the 
vessel  have  now  completely  separated  from  one  another,  but  form  at 
each  end  a  firmly  closed  cul-de-sac,  which  still  shuts  out  all  external 
growth.  (Frontispiece,  Fig.  I.)  As  two  weeks  have  elapsed  by  this 
time,  it  is  not  unnatural  that  observers  should  have  supposed  that 
union  had  taken  place,  but  in  reality  we  are  only  approaching  the 
beginning  of  the  second  stage  of  the  process.  The  ligature,  which 
is  now  entirely  independent  of  the  vessel,  becomes  encysted;  or,  if 
it  be  made  of  material  that  is  easily  absorbed,  is  found  infiltrated 
with  granulation  cells,  or  it  may  have  disappeared  entirely.  Under 
the  old  system  of  leaving  one  end  of  the  ligature  protruding  from 
the  wound,  it  would  by  this  time  have  become  sufificiently  detached 
from  the  tissues,  which  it  had  originally  surrounded,  to  enable  the 
surgeon  to  withdraw  it,  provided  the  callus  did  not  hold  the  knot  too 
firmly  in  its  grasp.  Occasionally  the  suppuration  would  be  sufficient 
to  discharge  it  through  an  open  sinus,  as  seen  in  the  Frontispiece 
(Fig.  II.).  Strictly  speaking,  the  ligature  does  not  ulcerate  through 
the  walls  of  the  vessels,  as  an  elastic  ligature  does  through  tissues 
which  it  encloses.  Having  constricted  the  adventitia  into  a  tendinous- 
like  band  at  the  moment  of  its  application,  it  remains  encircling  this 
tissue  like  a  ring  upon  the  finger.  The  softening  of  the  vessel-wall 
is  accomplished  by  the  granulation  cells,  and  this  process  is  really 
more  marked  after  the  ligature  has  separated  entirely  from  the  vessel. 
The  sole  function  of  the  ligature,  after  it  has  closed  the  vessel,  is 
to  keep  the  walls  from  expanding  until  they  are  held  sufficiently 
firmly  by  the  callus. 

During  the  third  week,  the  granulation  tissue  has  so  infiltrated 
the  inner  and  middle  coats  of  the  vessel  at  the  point  where  they 
were  drawn  together  by  the  ligature,  that  they  retract  slightly,  and 
allow  the  granulation  tissue  to  insert  itself  between  them,  and  to 
invade  the  interior  of  the  vessel.  This  is  a  somewhat  critical  period 
in  the  process  of  repair,  for,  if  there  has  been  a  softening  of  the 
callus  by  suppuration,  it  may  not  be  sufficiently  strong  to  restrain 
this  retraction  and  the  throinbus  maybe  forced  out  (Fig.  14)  unless 
it  be  firmly  secured  to  the  vessel-wall  by  the  process  alluded  to 
above. 


Snviiiiary.  145 

The  second  stage  begins  somewhat  earher  in  dogs  than  in  man 
or  horses,  and  varies  greatly  according  to  the  amount  of  inflamma- 
tion. When  the  latter  is  severe  it  may  already  have  begun  at  the 
end  of  the  first  week  (Fig.  8).  It  is  not,  however,  until  the  end  of 
the  first  month  that  we  see  the  walls  of  the  vessel  open  nearly  to 
their  original  distance  from  one  another,  and  the  granulation  tissue 
invading  in  mass  the  interior  (Figs.  11  and  16).  As  this  growth 
of  tissue  pushes  forward,  it  infiltrates  the  lower  layers  of  the 
thrombus,  as  in  Figure  16,  or  it  pushes  the  clot  before  it,  as  in  Figure 
11: — The  greater  portion  of  the  thrombus  is,  however,  eventually 
infiltrated  by  these  granulations,  which,  later,  are  seen  communicat- 
ing directly  with  the  lumen  of  the  vessel  (Fig.  18).  In  cross  section 
the  relations  of  the  two  are  well  shown  (Fig.  17),  the  newly  formed 
tissue  appearing  honey-combed  by  blood-spaces,  giving  it  a  cavernous 
structure.  Viewed  in  long  sections,  the  internal  growth  extends 
up  on  either  wall  somewhat  farther  than  in  the  centre,  and  generally 
a  longer  distance  on  one  side  than  on  the  other.    (Fig.  16). 

The  appearance  of  the  vessel  at  this  period  is  striking  (Frontis- 
piece, Fig.  II).  The  walls  have  opened  widely,  and  are  imbedded  in 
a  mass  of  newly  formed  tissue,  which  surrounds  and  is  inserted 
between  them.  On  the  upper  surface  of  the  inner  growth  or  callus, 
the  remains  of  the  thrombus  are  usually  seen  covering  the  granula- 
tions, like  a  scab. 

Where  the  thrombus  has  been  a  large  one  it  appears,  to  the  naked 
eye,  not  to  have  changed,  but  an  examination  with  a  lower  power  dis- 
closes the  fact  that  most  of  the  blood  corpuscles  have  disappeared, 
and  that  granulation-cells  and  fibres  have  taken  their  place.  The 
thrombus  has,  according  to  the  old  view,  become  organized;  or, 
according  to  more  modern  ideas,  has  been  absorbed.  It  has  served 
as  a  good  neutral  medium  for  the  granulation  cells  to  grow  in,  and 
has  acted  as  a  sort  of  model,  giving  to  the  new  tissue,  to  a  certain 
extent,  its  outward  form.  This  tissue  of  the  internal  callus  is  rich 
in  capillaries  which  grow  in  with  the  tissue,  taking  their  origin  from 
the  vessels  of  the  external  callus;  they  ramify  in  the  granulations,  but 
do  not  as  yet  communicate  with  the  lumen  of  the  vessel.  In  some 
specimens  it  was  possible  to  follow  their  development  (Plate  IV), 
which  had  all  the  appearance  of  being  of  that  variety  known  as  the 
intercellular,  the  spindle-shaped  cells  grouping  themselves  in  bundles, 
and  forming  channels  which  communicate  directly  with  the  capillary 
system. 

The  time  when  the  capillaries  communicate  with  the  lumen  has 
10 


146  Tlic  Ligature  of  Arteries. 

been  a  subject  of  much  discussion.  It  is  probable  that,  in  many 
cases  this  occurs  to  a  Umited  extent  only,  as  the  majority  of  them 
have  simply  a  temporary  existence.  In  larger  cicatrices,  however, 
(Fig.  27),  the  new  tissue  is  rich  in  fine  capillaries  and  arterioles, 
which  communicate  freely  with  the  blood  spaces.  In  such  cases 
communication  is  not  probably  established  until  the  tissue  has  dif- 
ferentiated to  such  an  extent  as  to  become  more  nearly  like  the 
permanent  cicatricial  tissue.  This  does  not  occur  until  the  beg'.nning 
of  the  final  or  third  stage;  that  is,  at  the  end  of  the  second  or  the 
beginning  of  the  third  month. 

Figure  III.  of  the  frontispiece,  although  taken  from  a  preparation 
of  four  months,  an  unusual  period,  serves  well  as  an  illustration  of 
the  early  part  of  the  final  stage  of  the  process  of  repair.  The  ex- 
ternal callus  has  already  entered  upon  a  retrograde  change.  While  the 
process  of  absorption  is  taking  place  without  the  vessel,  a  process  of 
differentiation  of  the  cell-elements  is  taking  place  within.  Already 
we  see  numbers  of  spindle-shaped  cells  with  staff-shaped  nuclei, 
particularly  near  the  upper  surface  of  the  granulation  tissue,  or  that 
nearest  the  lumen. 

The  ligature  at  this  period  may  have  been  cast  off,  or  it  may 
have  been  absorbed,  or  it  may  remain  encysted  in  the  callus.  Fre- 
quently the  catgut  ligature,  and  the  cotton  also,  will  have  disappeared 
long  before  this.  The  silk  ligature  has  been  observed  as  long  as 
four  months  after  its  application.  No  experiments  were  made  to 
test  the  different  materials  commonly  used  for  this  purpose. 

The  third  and  final  stage  comprises  that  period  during  which 
the  provisional  structures  are  absorbed,  and  the  permanent  cicatricial 
tissue  is  developed  in  their  place.  The  cicatrix  is  situated  between 
the  ends  of  the  vessel-walls,  which  are  still  separated  from  one 
another,  and  is  composed  of  three  constituent  parts:  the  endothelial, 
the  muscular,  and  the  connective  tissue  portions.  In  small  cicatrices 
which  occupy  only  a  short  segment  of  the  interior  of  the  vessel,  these 
tissues  are  arranged  in  layers,  the  endothelium  covering  the  muscular 
fibre,  beneath  which  lies  the  connective  tissue,  which  is  continuous 
with  the  cord.  (Frontispiece, Fig.  IV.  and  Fig.  20).  In  long  cicatrices, 
such  as  are  seen  in  the  largest  vessels  in  man,  we  have  a  more  com- 
plicated arrangement  The  lumen  is  obliterated  for  a  considerable 
distance  by  a  tissue  filled  with  vascular  spaces,  the  muscular  cells 
being  arranged  chiefly  in  circular  bands  around  these  spaces.  Here 
a  condition  obtains  more  nearly  resembling  that  seen  in  the  arteries 
of  amputation  stumps,  or,  as  far  as  it  goes,  in  endarteritis  obliterans. 


Suvimary.  147 

A  large  portion  of  this  tissue  consists  of  a  delicate  mucous  tissue 
with  branching  cells,  round  cells,  and  delicate  fibres,  and  filled  with 
capillaries  and  arterioles,  forming  a  system  which  communicates, 
here  and  there,  with  the  large  cavernous  blood-spaces.  These  latter 
ramify  throughout  the  whole  length  of  the  cicatricial  tissue,  but  do 
not  project  beyond  the  slightly  incurved  walls  at  the  end  of  the  vessel. 
(Fig.  27).  Here  the  tissue  comes  in  contact  with  the  bundles  of 
fibrillated  tissue  of  which  the  cord  is  composed.  The  muscular 
fibres  are  massed  chiefly  near  the  open  lumen  of  the  vessel  and 
around  the  blood-spaces,  a  few  of  them  being  arranged  longitudinally. 
The  muscular  cells  were  subjected  to  a  great  variety  of  tests  to 
determine  their  true  character.  In  dogs  a  number  of  specimens  were 
cut  transversely,  and  here  they  appeared  as  round  cells,  (Fig.  24.) 
In  Figure  25  they  are  arranged  in  the  rent  in  the  mediae,  in  cir- 
cular bands,  and  again  show  in  cross  section.  In  other  speci- 
mens they  are  seen  to  emerge  from  the  clefts  in  the  lamina 
elastica,  and  to  be  directly  continuous  with  the  muscular  cells 
of  the  media,  whether  the  vessel  be  studied  in  longitudinal  (Fig. 
28)  or  in  cross  sections  (Fig.  23).  In  the  latter  drawing,  the 
muscular  cells  of  the  media  are  seen  on  the  right  hand,  and  the 
newly  formed  cells  in  the  cicatrix  on  the  left.  In  longitudinal 
sections,  the  long  staff-shaped  nuclei  are  brought  out  distinctly  in 
sections  mounted  in  Canada  balsam  (Figs.  22  and  28),  and,  in  Figures 
21  and  23,  the  bodies  of  the  cells  show  well  in  glycerine  prepara- 
tions. In  Figure  23,  the  cross  section  is  taken  at  a  point  nearly 
corresponding  in  Figure  20,  to  the  line  V.  A  great  variety  of  stain- 
ing fluids  were  used,  all  of  them  bringing  out  the  characteristic 
nuclei.  It  has  been  maintained  that  cells  of  this  appearance  may 
be  seen  in  cicatricial  connective  tissue,  but  there  seems  nothing  im- 
probable, or  contrary  to  nature,  in  the  hypothesis  that  they  are  de- 
rived from  muscular  tissue.  The  proliferation  of  the  muscular 
cells  of  the  media  in  the  walls  of  the  arteries  of  horses  was  observed 
in  the  specmens  recorded  in  the  series  of  experiments  on  horses. 
In  dogs,  the  growth  of  these  cells  into  the  cicatricial  tissue  has  just 
been  alluded  to,  and  in  man  the  cells  of  the  cicatricial  tissue  have 
the  same  marked  type.  Muscular  cells  are  formed  in  large  numbers 
around  vessels  of  considerable  size,  in  the  obliterating  tissue  of 
arteries,  and  a  similar  arrangement  of  such  cells  is  seen  in  the  new 
tissue  formed  within  the  walls  of  the  hypogastric  artery.  In  the 
aortic  cicatrix,  and  in  the  cicatrix  of  the  pulmonary  artery,  at  the 
ends  of  the  ligamentum  arteriosum,  we  see  masses  of  such  cells  di- 


148  The  Ligature  of  Arteries. 

rectly  continuous  with  the  muscular  coats  of  those  vessels.  Finally, 
the  many  excellent  opportunities  to  compare  these  cells  with  the  mus- 
cular cells  of  the  vessel-walls  in  immediate  contact  with  them,  leave 
no  reasonable  doubt  as  to  their  identity.  The  new  formation  of 
muscular  fibre  is  not  an  unusual  occurrence.  We  see  cells  of  this 
nature  formed  in  abundance  wherever  new  arterioles  grow  in  inflam- 
matory tissue.  The  walls  of  the  uterus  furnish  a  physiological 
example  of  the  development  of  muscular  cells  on  a  large  scale,  and 
they  are  also  seen  forming  a  very  considerable  portion  of  the  morbid 
growths  in  the  fibro-myomata.* 

The  shape  of  the  cicatrix  in  the  interior  of  arteries,  as  well  as 
its  size,  varies  considerably.  In  all  cases  it  is  so  disposed  within  the 
vessel  that  there  shall  be  a  gradual  narrowing  of  the  lumen  until  it 
becomes  the  size  of  an  arteriole.  In  moderately  large  vessels  this 
is  accomplished  without  great  difificulty,  but  in  full-sized  vessels  the 
cicatrix  is  elongated  and  composed  of  cavernous  tissue,  by  means  of 
which  the  blood-current  is  allowed  to  circulate  in  a  system  which  is 
the  equivalent  of  an  elongated  vessel  gradually  narrowing  in  calibre, 
and  coiling  up  in  a  confined  space.  The  strain  upon  the  cicatrix 
is  thus  probably  greatly  relieved.  The  shape  of  the  cicatrix  is  also 
such  as  to  adapt  the  lumen  to  the  diminished  blood-supply  which 
now  is  sent  in  this  direction.  This  supply  will  depend  upon  the 
proximity  of  a  large  branch.  If  there  be  no  branch  in  the  immedi- 
ate vicinity,  the  cicatrix  will  extend  for  some  distance  farther  up 
the  sides  of  the  vessel  than  in  the  centre  (Frontispiece,  Fig.  IV.), 
and  a  small  arteriole  will  take  its  origin  from  the  apex  of  the  cul-de- 
sac  thus  formed.  If  a  large  branch  be  close  at  hand,  one  horn  of 
the  cicatrix  will  extend  up  on  the  opposite  side,  adjusting  the  size 
of  the  current  to  the  needs  of  the  collateral  circulation,  so  that  no 
abrupt  change  in  the  diameter  of  the  circulating  column  of  blood  can 
occur  (Fig.  26).  The  strain  brought  upon  the  wall  of  a  vessel  at  the 
point  of  a  narrow  outlet,  from  a  large  arterial  blood-space  which  had 
no  other  exit,  would  be  too  great.  We  find  in  fact  that  the  exit  of 
all  large  vessels  from  the  aorta  are  supported  by  an  extra  develop- 
ment of  muscular  tissue,  so  placed  at  the  angle  in  the  wall  as  best 
to  support  the  pressure  brought  to  bear  upon  it.  The  cicatrix  is 
said  to  be  asymmetrical,  or  symmetrical  according  to  these  varying 
conditions.     It  is  probable  that  no  cicatrix  is  perfectly  symmetrical, 

*  For  a  recent  observation  of  this  kind,  see  Amer.  Jour.  Med.  Sci.,  April,  1886, 
p.  511. 


Siuiiniary.  149 

for  the  neighborhood  of  a  branch  or  branches  will  affect  the  size  of 
one  of  its  horns,  more  or  less,  in  almost  every  case. 

The  cord  which  unites  the  two  ends  of  the  vessel  varies  greatly, 
of  course,  in  length.  When  a  vessel  has  been  tied  between  power- 
ful branches,  as  certain  parts  of  the  subclavian,  the  ends  of  the 
vessel  will  retract  but  a  short  distance  from  one  another,  and  but 
little  of  the  vessel-wall  will  be  absorbed.  On  the  other  hand,  if  the 
ligature  be  placed  upon  a  long  branchless  trunk,  like  the  common 
carotid,  the  cord  will  be  unusually  long.  In  the  latter  case  there 
has  been,  not  only  a  retraction  of  the  ends  of  the  vessel,  but  also 
an  actual  absorption  of  portions  of  the  vessel-walls,  which  have  now 
become  useless.  (Fig.  27).  The  study  of  the  behavior  of  vessels 
in  this  respect,  not  only  after  ligature  in  man  and  animals,  but  also 
after  closure  of  the  hypogastric  artery,  confirms  this  view.  The  cord 
does  not,  however,  represent  the  fibrous  remains  of  the  vessel-wall, 
but  the  final  stage  of  development  of  the  tissue  of  which  the  ex- 
ternal callus  is  composed.  The  greater  portion  of  this  structure,  is, 
like  the  internal  callus,  absorbed  and  the  cord  may  be  regarded  as 
its  cicatricial  remains. 

The  cicatrix  of  an  artery,  after  ligature  in  its  continuity,  bears  a 
close  resemblance  to  the  cicatrix  in  the  aorta  and  in  the  pulmonary 
artery,  marking  the  former  openings  of  the  ductus  arteriosus.  We 
find  here  the  central  arteriole  surrounded  by  a  delicate  muscular 
tissue,  enclosed  between  the  ends  of  the  media,  which  terminate 
abruptly  a  short  distance  from  one  another.  The  comparison  is 
interesting  as  throwing  light  upon  the  nature  of  the  tissues  involved 
in  the  new  cicatrix. 

The  appearances  observed  in  the  interior  of  an  artery  of  an 
amputation  stump  do  not  differ  essentially  during  the  first  week  from 
those  seen  after  ligature  in  continuity.  A  slight  difference  is 
noticed  in  the  incurvation  of  the  media,  in  vessels  which  have  been 
seized  at.  the  end  by  forceps,  the  adventitia  being  drawn  forward 
over  the  rolled-up  media.  This  is  not  always  seen,  however,  in 
amputation  stumps.  At  the  end  of  this  time,  there  is  a  marked 
divergence  in  the  two  processes.  In  the  interior  of  the  stump  of  the 
amputated  artery,  there  is  a  thickening  of  the  intima  for  a  consid- 
erable distance  from  the  point  of  ligature.  Probably  this  change 
can  be  followed  to  the  neighborhood  of  the  origin  of  the  vessel. 
By  the  end  of  the  third  week,  the  lumen  of  the  vessel  is  greatly 
diminished  in  calibre.  The  character  of  this  growth  is  shown  well 
in  the  drawings   (Figs.   5   and  15).     It  consists  of   a  myxomatous 


150  TJic  Ligature  of  Arteries. 

tissue  containing  spindle-shaped  and  round  cells;  in  some  instances 
small  blood-vessels  are  seen  as  early  as  the  third  week. 

The  size  of  the  thrombus  varies  greatly,  and  not  always  accord- 
ing to  the  proximity  of  a  branch,  or  the  amount  of  sepsis.  The 
tenacity  with  which  the  growth  from  the  walls,  or  through  the  walls, 
will  hold  a  thrombus,  even  when  the  end  of  the  vessel  has  been 
opened  by  suppuration,  is  shown  in  Fig.  14.  After  withdrawing  the 
needle  in  acupressure  the  ends  of  the  vessel  may  open  in  this  way, 
but  the  firmness  with  which  the  clot  is  held  prevents  its  expulsion. 
There  is  probably  some  infiltration  of  the  clot  with  wandering  cells, 
and  also  a  growth  from  the  intima,  which  gives  this  security  in  these 
cases. 

In  the  completed  process  of  cicatrization  we  find  a  condition  ap- 
parently very  different  from  that  above  described  in  ligature  in  con- 
tinuity, but  which  is,  in  reality,  a  further  elaboration  of  the  same 
process,  by  which  the  vessel  is  adapted  to  the  needs  of  the  circula- 
tion. The  entire  lumen  of  the  vessel  must  be  narrowed  for  this 
purpose,  and,  since  this  cannot  be  effected  by  a  simple  contraction 
of  the  walls,  the  cicatrix  is  continued  up  through  the  lumen  to  the 
point  of  origin  of  some  large  collateral  branch.  An  obliterating 
endarteritis  has  taken  place,  and  in  the  new  tissue  we  see  the  lumina 
of  several  smaller  vessels.  This  condition  resembles  that  seen  in 
the  carotid  after  ligature  in  continuity  (Fig.  27),  but  it  extends 
through  a  greater  part  of  the  vessel.  A  study  of  the  tissues  in  the 
two  cases  shows  no  essential  differences;  we  have,  in  both,  the  internal 
blood-spaces  or  vessels,  the  surrounding  bands  of  muscular  fibre, 
and  the  connective  tissue  formation.  We  see  in  the  latter  case  also, 
although  in  a  different  shape,  the  gradual  tapering  of  the  lumen  of 
the  vessel  until  it  terminates  in  a  fine  arteriole  which  communicates 
with  capillaries.  In  the  former  case  the  lumen  is  not  coiled  up  in  a 
small  space,  but  is  extended  out  through  the  whole  length  of  the 
stump.  The  true  character  of  the  process  of  repair  could  not  be 
well  shown  by  a  dissection-preparation  of  the  vessel  of  the  stump, 
for  in  the  femoral  artery,  mentioned  above,  the  outward  form  still 
remains,  although  the  lumen  has  been  altered  into  a  number  of  in- 
tertwining vessels.  The  object  would  be  best  accomplished  by  a 
corrosion-specimen,  which  would  show  only  the  respective  calibres 
of  the  vessels,  in  which  case  we  should  probably  see  the  main  artery, 
soon  after  it  entered  the  limb,  breaking  up  into  a  spray  of  smaller 
vessels,  which,  with  collaterals  of  a  similar  size,  would  be  distributed 
equally  to  different  parts  of  the  stump. 


Sjtvimary.  1 5 1 

The  repair  after  closure  of  the  hypogastric  artery  is  precisely 
similar,  like  conditions  as  to  circulation  prevailing  here.  We  see  the 
early  thickening  of  the  intima,  and  the  final  obliterating  tissue 
pierced  by  a  blood-vessel,  with  new  muscular  walls.  In  the  same 
category  can  be  placed  the  vessels  which  have  become  obliterated 
spontaneously  by  a  growth  within  their  walls.  The  possible  origin 
of  this  growth,  in  response  to  a  demand  that  has  been  made  upon 
the  walls  of  the  vessels,  to  meet  the  necessities  of  a  diminished 
blood  supply,  has  already  been  suggested.  Such  a  change  extending 
so  far  from  the  original  seat  of  the  traumatic  inflammation,  should 
be  regarded  as  formative  rather  than  inflammatory.  This  example 
serves  to  emphasize  the  difference  between  repair  and  inflammation. 

The  old  view  that  this  obliteration  is  the  result  of  a  "  thickening 
of  the  intima,"  that  is,  a  growth  solely  from  the  cells  of  the  intima, 
is  untenable  in  the  light  of  these  investigations.  The  bulk  and 
strength  of  the  arterial  wall  lies  largely  in  its  middle  coat,  and,  on 
a  priori  grounds  alone,  it  seems  improbable  that  this  coat  should  take 
no  part  in  processes  which  are  of  so  vital  import  to  its  future  useful- 
ness. In  the  experiments  given  here  we  see  coming  from  this  layer 
actual  growths,  and  a  proliferation  of  the  muscular  cells  which  it  con- 
tains, and  it  is  highly  probable  also  that  a  considerable  amount  of 
connective  tissue  may  be  derived  from  this  coat.  It  is  somewhat 
remarkable  that  in  all  the  investigations  we  have  quoted  in  the  his- 
torical summary  no  mention  is  made  of  such  a  possibility.  Herein 
lies  the  secret  of  the  security  of  the  ligature,  and  of  the  fact  that  after 
this  operation  no  aneurismal  dilatation  of  the  vessel  takes  place. 
In  wounds  of  the  walls  of  arteries  the  circulation  is  re-established 
long  before  a  durable  cicatrix,  which  requires  months  for  its  forma- 
tion, has  been  developed,  and  the  tender  and  non-contractile  tissue 
is  easily  dilated  by  the  pressure  of  the  column  of  blood.  The  power- 
ful provisional  structures,  which  develop  after  ligature,  are  sufficient 
to  control  this  pressure  until  the  young  cicatrix  has  grown  strong 
enough  to  do  its  work  without  their  aid. 

Since  the  ligature  became  an  important  feature  of  operative  sur- 
gery, a  great  deal  of  ingenuity  has  been  expended  in  the  effort  to 
occlude  the  vessel  without  subjecting  it  to  the  dangers  of  secondary 
hemorrhage.  For  this  purpose,  it  was  at  one  time  thought  advisable 
to  apply  several  ligatures  to  the  vessel,  side  by  side,  in  order  to 
bring  a  great  portion  of  the  walls  in  contact  with  one  another;  later, 
broad  and  flat  ligatures  were  also  employed  for  the  same  purpose. 
Attempts  were  also  made   to   imitate  more  closely  the  obstruction  of 


152  The  Ligature  of  Arteries. 

the  circulation  by  compression  b}-  means  of  the  application  of  two 
ligatures,  near  together,  which  held  the  walls  gently  in  contact  with- 
out rupturing  the  inner  coats.  Another  supposed  improvement  over 
the  simple  ligature  in  continuity  consisted  in  the  application  of  two 
ligatures,  and  the  division  of  the  vessel  between  them,  in  order  that 
the  tendency  of  each  end  to  retract  might  not  tear  the  two  fragments 
apart  before  they  had  been  effectively  sealed  by  the  healing  process. 
In  acupressure  and  torsion  a  new  principle  was  touched.  The  design 
was  to  avoid,  by  these  methods,  the  presence  of  a  substance  which 
interfered  with  repair.  The  ligature  as  formerly  applied  produced 
conditions  similar  to  those  which  prevail  in  bones  subjected  to  com- 
pound fracture.  The  long  end  of  the  thread  prevented  closure  of 
the  wound,  and  favoured  suppuration  at  a  point  where  union  by  first 
intention  was  the  great  object  to  be  attained.  If  both  ends  were  cut 
short,  it  was  supposed  that  the  knot  would  eventually  work  its  way 
out,  like  any  other  foreign  body,  and,  under  the  conditions  which 
prevailed  before  aseptic  precautions  were  employed,  this  was  usually 
the  case.  Even  with  the  advantages  which  antiseptic  surgery  gave, 
it  was  thought  necessary  to  employ  some  material  which  could  be 
subsequently  disintegrated  and  absorbed.  The  animal  ligature  was 
then  introduced  with  this  object  in  view.  We  now  know  that  both 
silk  and  hempen  ligatures  can  become  either  encysted  or  absorbed; 
in  other  words,  they  can  be  so  applied  as  not  to  interfere  with  the 
healing  process. 

Provided  the  ligature  be  adjusted  so  as  to  obstruct  permanently 
the  flow  of  blood  through  the  vessel,  it  is  manifest,  from  the  observa- 
tions which  have  been  described,  that  a  destruction  of  a  certain  por- 
tion of  the  vessel-walls,  and  a  retraction  of  the  ends  of  the  vessel, 
must  eventually  take  place,  no  matter  what  the  nature  of  the  material 
may  be,  or  how  it  be  applied. 

The  prime  object,  therefore,  to  be  obtained,  is  to  employ  such 
methods  as  will  interfere  as  little  as  possible  with  the  natural  sequence 
of  events  which  follow  one  another  during  the  process  of  repair 
under  the  most  favoral)le  conditions.  When  the  ends  of  the  vessel  are 
once  sealed  by  the  formation  of  an  external  ring  or  callus,  and  the 
rest  of  the  w^ound  is  promptly  healed  by  first  intention,  so  that  this 
growth  shall  not  be  prematurely  broken  down  by  suppuration,  all 
danger  of  hemorrhage  is  avoided.  The  rules  of  antiseptic  surgery 
supply  us,  therefore,  with  a  more  certain  method  of  securing  this 
desirable  result  than  any  other  plan  which,  up  to  the  present  time, 
has  been  proposed. 


APPENDIX. 


METHODS. 

All  fresh  specimens  vere  placed  immediately  in  Muller's  fluid, 
and  kept  there  during  a  period  varying  from  two  days  to  three  weeks, 
according  to  the  size  of  the  vessel.  After  being  thoroughly  washed 
in  water,  they  were  placed  in  strong  alcohol. 

In  case  the  thrombus  was  the  object  of  study,  the  vessel  was 
opened  before  placing  it  in  any  preservative  fluid.  The  material 
found  best  for  imbedding  was  celloidin,  paraffine  frequently  render- 
ing the  thrombus  so  tough  as  to  turn  the  edge  of  a  razor.  In  im- 
bedding in  celloidin  care  should  be  taken  to  allow  the  material  to 
flow  into  the  lumen  of  the  artery:  the  vessel  should,  therefore,  be 
cut  open  as  close  to  the  point  of  ligature  as  possible,  to  permit  the 
bubbles  of  air  to  escape;  otherwise,  the  edge  of  the  wall  opposite 
an  air  bubble  will  bend  under  the  razor,  and  be  cut  obliquely  in  con- 
sequence. 

Longitudinal  sections  proved  to  be  much  more  instructive,  as  a 
rule,  than  transverse  sections.  No  attempt  was  made  to  arrange  the 
longitudinal  sections  in  serial  order,  for  a  little  experience  enables 
one  to  distinguish  between  those  which  come  from  the  centre  of  the 
specimen,  and  those  from  the  upper  and  lower  surfaces.  An  inexpe- 
rienced observer  can,  however,  be  easily  deceived  by  an  apparent 
thickening  of  a  particular  portion  of  the  wall,  due  to  the  obliquity  of 
the  section.  This  danger  is  avoided  by  selecting  the  central  sec- 
tions. 

In  making  cross  sections,  more  attention  should  be  paid  to  pre- 
serving a  knowledge  of  the  order  in  which  they  have  been  made.  In 
specimens  taken  from  ligatured  arteries,  it  was  usually  sufficient  to 
separate  the  proximal  from  the  distal  portions  before  imbedding  for 
cross  sections;  but  where  an  entire  vessel  was  examined,  like  the 
hypogastric  artery,  it  was  found  necessary  to  divide  the  specimen  into 
seven  or  eight  different  segments,  which  were  numbered  to  corre- 
spond to  the  figures  on  a  diagram  preserved  for  the  purpose.  Some  of 
these  segments  were  cut  into  longitudinal,  and  some  into  transverse 
sections.     In  studying  the  ductus  arteriosus,  the  best  results  were 


154  ^/^^  Ligature  of  Artci'ics. 

obtained  by  cutting  the  specimens  into  halves,  whether  for  the  pur- 
pose of  making  longitudinal  or  transverse  sections.  Haematoxyline 
was  the  staining  fluid  chiefly  used,  although  many  of  the  aniline  d3^es 
were  experimented  with  in  studying  muscular  fibre.  Very  ornamen- 
tal specimens  were  obtained  by  the  double  staining  with  eosine  and 
hsematoxyline.  The  best  material  for  mounting  proved  to  be  Canada 
balsam,  owing  to  the  transparency  of  the  thrombus  in  this  medium. 
Glycerine  was  also  used,  but  chiefly  for  detail  studies  of  cell- 
structures. 

The  student's  Hartnack-microscope  was  the  instrument  chiefly 
used,  and  the  numbers  given  in  the  explanation  of  the  figures  are 
those  of  the  lenses  used  with  this  instrument.  The  highest  power 
ordinarily  employed  was  the  nine-immersion  lens,  although  Zeiss' 
oil-immersions  were  occasionally  used.  High  powers  were,  however, 
rarely  needed.  The  letter  t,  used  in  describing  the  power,  refers 
to  the  slight  increase  of  power  produced  by  the  drawing  out  of  the 
tube.  In  carrying  out  aseptic  precautions  in  the  ligature  of  arteries 
in  dogs,  the  spray  was  usually  employed  although  equally  good  re- 
sults were  obtained  without  it.  The  animal  should  be  washed  the 
day  before  the  operation,  and  before  making  the  incision  the  integu- 
ments over  the  vessel  should  l)e  shaved  and  thoroughly  scrubbed 
with  one-to-forty  carbolic  wash.  It  is  well  also  to  dust  on  iodoform 
powder  at  this  time.  All  usual  precautions  in  the  care  of  instruments 
and  hands  should,  of  course,  be  taken.  A  few  strands  of  carbolized 
gut  should  be  made  to  serve  as  a  drain  to  the  more  superficial  por- 
tions of  the  wound,  and  catgut  sutures  should  be  employed.  The 
material  used  for  the  ligature  varies,  of  course,  according  to  the  de- 
signs of  the  operator.  The  wound  and  the  neighboring  parts  should 
be  thoroughly  dusted  with  iodoform,  which  is  peculiarly  well  adapted 
for  these  cases,  as  the  hair  retains  the  powder  quite  as  well  as  it 
does  dirt.  A  borated  cotton-dressing  can  be  easily  retained,  either 
around  the  neck  or  the  groin  by  a  free  use  of  the  spica  bandage, 
and,  when  properly  applied,  it  will  be  found  at  the  end  of  the  week, 
the  length  of  time  it  was  usually  left  on,  not  to  have  been  disarranged 
in  the  least.  As  an  additional  precaution,  it  is  well  to  dust  in  a  little 
iodoform  daily,  about  the  edge  of  the  dressing,  and  the  animal 
should  be  kept  shut  up  alone,  during  the  healing  process. 

The  ver)'  marked  difference  in  the  healing  of  wounds  treated  in 
this  way  and  of  those  in  which  no  antiseptic  precautions  were  taken, 
together  with  the  ease  with  which  antisepsis  was  carried  out,  are  strong 
proofs  in  favor  of  the  usefulness  of  this  method  of  treatment  of  the 


Methods.  1 5  5 

wounds  of  animals.     The  use  of  iodoform  is  strongly  recommended, 
owing  to  the  peculiar  tenacity  with  which  it  clings  to  the  hair. 

The  wounds  made  in  experiments  on  horses  were  not  treated  in 
this  way,  and  healing  was  protracted,  and  occasionally  inflammation 
was  excessive.  The  use  of  iodoform  before,  during,  and  after  an 
operation  on  this  useful  animal,  ought  to  be  of  great  value  in  ob- 
taining satisfactory  results. 


i 


I 


DESCRIPTION  OF  PLATES. 


FRONTISPIECE. 


I. — Carotid  arter)'  of  horse  two  weeks  after  ligature.  The  specimen 
shows  the  external  callus  and  the  thrombus:  in  this  specimen 
the  proximal  thrombus  is  white,  for  what  reason  does  not  appear. 
The  walls  of  the  vessel  are  continuous  around  the  base  of  each 
thrombus,  and  they  appear  to  have  united  by  first  intention, 
which  is  not  the  case. 

II. — Carotid  artery  of  horse  two  months  after  ligature,  showing  the 
external  and  internal  callus,  and  the  open  ends  of  the  vessel. 
The  second  stage  of  repair. 

III. — Carotid  artery  of  horse  four  months  after  ligature.  The  third 
stage  of  repair.     Absorption  of  the  external  callus. 

IV. — The  external  iliac  artery.  Man.  One  hundred  and  thirty  days 
after  ligature.  Termination  of  the  third  stage.  Formation  of 
muscular  cicatrix. 

PLATES. 

A.   Adventitia.  B.  Blood-clot.   C.   Ligament.   D.  Pigment. 
E.   Lamina  Elastica.   F.   Muscular  cells.  G.  Granulation  tissue. 
H.  Granulations.   I.  Intima.   K.   Endothelium.   L.   Ligature. 
M.   Media.   N.  New  Growth.   P.   Periadventitia. 
S.   Blood  Spaces.  T.  Thrombus.  V.   Vessel. 
The  number  of  each  Hartnack  objective  and  eye-piece  is  given. 
The  letter  t  indicates  that  the  tube  of  the  microscope  was  drawn  out. 

PLATE    I. 

Fig.  I.   (2X2xt). — Femoral  artery  of  dog,  two  days  after  ligature. 

The  action  of  the  ligature  on  the  walls  is  shown:  wandering  cells 

are  entering  the  thrombus,  and  granulation  tissue  surrounds  the 

knot. 
Fig.   2.   (2x2). — Carotid  artery  of  dog  four  days  after  ligature.     The 

upper  end,  the  proximal  portion,  is  distended:  the  distal  end  is 


158  TJic  Ligature  of  Arteries. 

contracted.     The  white  corpuscles  have  not  wandered  in,  but 
belong  to  the  clot. 

PLATE    II. 

Fig.  3.  (9X2xt). — Proliferation  of  the  endothelium  in  the  distal  por- 
tion of  Fig.  2.  Mother-cells,  spindle-cells,  endothelium  and 
blood-corpuscles  are  shown. 

Fig.  4.  (2x2). — Brachial  artery  of  man,  two  hours  after  laceration. 
The  external  and  internal  thrombus  are  shown,  and  the  curling 
of  one  side  of  the  vessel. 

Fig.  5.  (9X3xt). — Tibial  artery,  from  amputation  stump  of  man,  three 
weeks  after  operation.  Growth  of  cells  in  the  intima.  The 
double  elastic  lamina  of  the  tibial  artery  is  also  shown. 

Fig.  6.  (7x3x1). — Carotid  artery  of  dog,  one  week  after  ligature. 
Rupture  of  elastic  lamina  at  a  point  some  distance  from  the  liga- 
ture.    Growth  of  cells  from  the  media  and  intima. 

PLATE    III. 

Fig.  7.   (9X3xt). — Femoral  artery  of  dog,  ten  days  after  ligature. 

Growth  of  endothelium  at  the  ruptured  edge  of  the  inner  coats 

at  the  point  of  ligature.     Blood  plaques  at  B. 
Fig.   8.   (2x2). — Femoral  artery   of  dog,    nine  days   after  ligature. 

Opening  of  the  distal  end  of  the  vessel.     Ingrowth  of  cavernous 

granulations.     No  clot  shown. 
Fig.  9.   (2x2). — Same  as  Fig.  7.     The  walls  have  not  separated,  but 

granulation  tissue  is  infiltrating  and  softening  them.   The  throm- 
bus is  attached  by  a  pedicle. 
Fig.    10.   (9X3xt). — SameasFig.  7.   A  growth  of  the  endothelium  over 

a  portion  of  the  wound  in  the  inner  wall.     Blood  plaques  at  B. 

PLATE    IV. 

Fig.  II.  (2x2). — Femoral  artery  of  dog  fourteen  days  after  double 
ligature.  Opening  of  the  ends  of  the  various  portions  of  the 
vessel,  with  ingrowth  of  granulations. 

Fig.  12.  (9x3x1). — Formation  of  capillary  vessel  beween  rows  of 
spindle-shaped  cells  at  point  V  in  Fig.  11. 

Fig.   13.   (9X4xt). — The  same  as  Fig.  12. 

PLATE    V. 

Fig.  14.  (2x2). — Tibial  artery  from  amputation  stump  of  man,  three 
weeks  after  operation.     Thrombus  protrudes  from  the  open  end 


Description  of  Plates.  i  59 

of  vessel,  owing  to   suppuration   in  wound.     Growth  in  intima. 
Infiltration  of  the  walls. 
Fig.  15.   (7X3xt). — Growth  in  intima  of  Fig.  14,  under  a  high  power. 
New  formed  blood-vessels  or  blood -spaces. 

PLATE  VI. 

Fig.  16.  (2x2). — Femoral  artery  of  dog,  one  month  after  ligature. 
Proximal  portion.  The  open  end  of  the  vessel  permits  the 
growth  of  granulation  tissue  into  the  interior.  Near  the  lumen 
granulations  are  seen.     The  clot  is  partially  absorbed. 

Fig.  17.  (2x3x1). — Femoral  artery  of  dog,  one  month  after  ligature. 
Cross  section  of  distal  portion  showing  the  growth  of  granula- 
tions into  the  lumen,  and  the  formation  of  blood-spaces  be- 
tween them. 

PLATE    VII. 

Fig.  18.  (7x3x1). — Detail  study  of  granulations  in  Fig.  16,  showing 
the  hyaline  structure  and  their  endothelial  covering,  also  the 
blood-spaces  between  them. 

Fig.  19.  (2x3x1). — Study  of  a  portion  of  the  proximal  end  of  Fig. 
17,  showing  a  rupture  of  the  elastic  lamina,  and  a  growth  into 
the  vessel  from  the  media.  This  growth  formed  a  diaphragm  a 
short  distance  above  the  apex  of  the  thrombus,  traces  of  which 
still  remained. 

PLATE    VIII. 

Fig.  20.  (4x3x1). — Femoral  artery  of  dog, three  months  after  ligature. 
The  appearance  of  the  final  cicatrix.  The  muscular  portion  (F) 
of  the  cicatrix  contrasting  with  the  connective  tissue  portion 
below  it.     The  asymmetry  of  the  cicatrix  is  also  shown. 

Fig.  21.  (9x4x1). — A  study  of  the  muscular  portion  of  Fig.  20,  the 
specimen  being  mounted  in  glycerine.  The  cells  on  the  left 
form  the  endothelial  covering. 

Fig.  22.  (9x4x1).- — A  similar  study  of  the  deeper  layers,  near  the 
elastic  lamina.     Specimen  mounted  in  Canada  balsam. 

PLATE    IX. 

Fig.  23.  (9x4x1).- — Cross  section  taken  on  about  a  level  with  the 
line  V  in  Fig.  20.  On  the  right  is  the  media;  on  the  left,  the 
new  muscular  cells  growing  from  it  into  the  cicatrix.  Glycerine 
preparation. 


i6o  TJie  Ligature  of  Arteries. 

Fig.  24.  (7x3x1). — Cross  section  from  the  cicatrix  in  the  carotid 
arter)^  of  a  dog,  four  months  after  ligature.  The  muscular  cells 
here  look  like  round  cells.  The  section  is  taken  about  oppo- 
site V  in  Fig.  26.     Canada  balsam  preparation. 

Fig.  25.  (4x3x1). — Wound  made  in  the  walls  of  carotid  artery  of  a 
dog,  by  applying  ligature,  and  removing  it  immediately.  Speci- 
men removed  three  months  after  ligature.  The  wound  is  partly 
filled  by  a  growth  of  new  muscular  tissue. 

PLATE    X. 

Fig.  26.  (2x2). — Carotid  artery  of  dog,  four  months  after  ligature. 
The  drawing  shows  the  shape  of  the  cicatrix  as  modified  by  the 
presence  of  a  branch. 

Fig.  27.  Natural  size.  Diagram  of  the  left  common  carotid  artery 
of  man,  four  years  after  ligature.  The  shape  and  cavernous 
structure  of  the  cicatrix  are  shown. 

Fig.  28.  (9x3x1). — Longitudinal  section  of  a  portion  of  the  cicatricial 
tissue  in  Fig.  26,  of  which  Fig.  24  is  a  cross  section.  The  en- 
dothelium is  seen  on  the  surface  and  below  the  muscular  cells, 
which  are  growing  through  a  rent  in  the  lamina  from  the  media. 
Canada  balsam  preparation. 

PLATE    XL 

Fig.  29.  (2X2xt). — The  aortic  end  of  the  ligamentum  arteriosum,  at 
forty-two  years,  in  the  human  subject.  The  ends  of  the  media 
aortae  are  seen  slightly  separated.  A  central  arteriole  follows 
the  axis  of  the  ligament,  and  is  surrounded  by  new  muscular 
cells.  On  a  level  with  C,  outside,  circular  muscular  fibres  are 
seen,  and,  in  the  two  inner  layers,  longitudinal  muscular  fibres. 
Around  the  point  of  origin  of  the  arteriole  is  a  growth  of  elastic 
tissue.     Section  taken  in  a  vertical  plane. 

Fig.  30.  (2X2xt). — Aortic  end  of  the  ligamentum  arteriosum,  at 
forty-two  days.  In  the  space  opposite  T  a  thrombus  existed. 
Around  this  space  are  seen  the  walls  of  the  ductus  arteriosus, 
in  a  state  of  hyaline  degeneration.  The  aortic  cicatrix  is  form- 
ing on  the  left.     The  section  is  taken  in  a  horizontal  plane. 

Fig.  31.  (2X2Xt). — Aortic  end  of  the  ligamentum  arteriosum  at 
thirty-eight  years.  The  usual  depression  in  the  aorta  is  want- 
ing; and  this  peculiarity  is  due  to  the  presence  of  a  large  amount 
of  elastic  tissue,  which  bridges  over  the  space  between  the  edges 


Description  of  Plates.  l6i 

of  the  media.     The  central  vessel  appears  to  come  from  the  pul- 
monary artery.     Patches  of  calcification  are  seen. 

PLATE    XII. 

Fig.  32.  (7X3xt). — Cross  section  of  the  hypogastric  artery  of  an 
adult;  showing  the  new  formed  muscular  and  elastic  layers, 
within  the  lumen  of  the  old  vessel. 

Fig.  2)Z-  (2x2.) — Femoral  artery,  taken  from  a  stump  at  least  fifteen 
years  after  amputation.  A  dissecting  room  subject.  The  cada- 
veric changes  prevented  staining;  but  the  specimen  shows  well 
the  new  tissue  formed  within  the  old  walls,  the  inner  borders  of 
which  are  marked  by  the  elastic  lamina.  Spots  of  calcification 
are  seen. 

Fig.  34.  (7X3xt.) — Hypogastric  artery  of  a  monkey.  The  new  vessel 
formed  within  the  old  shows  with  great  distinctness.  There  is 
no  new  elastic  lamina. 

Fig.  35.  (4X3xt). — Endarteritis  obliterans.  Cross  section  of  the 
tibial  artery,  in  human  subject.  The  media  is  much  altered 
and  calcified.  Tiie  lamina  elastica  is  broken.  The  new  tissue 
contains  a  large  vessel  with  new  formed  muscular  wall. 


BIBLIOGRAPHY. 


1.  B.C.  1500.  Susrutas  Ayur-V6das :  Id  est  medicinae  systenia,  a  venerabili 
D'harantare  demonstratum  a  Susruta  discipulo  compositum,  Hessler,  Erlangen, 
1844-50. 

2.  B.C.  400.  Hippocratis  medicorum  omnium  facile  principis  opera  omnia 
qufe  exstant  autore  Anutio  Faesio.  Frankfurt,  1621,  ii.,  1194.  The  genuine 
works  of  Hippocrates,  translated  from  the  Greek,  with  a  preliminary  discourse 
and  annotations  by  Francis  Atlams,  LL.D.,  London.     Sj-denham  Soc,  1849. 

3.  B.C.  30.  Aurelius  Cornelius  Celsus,  on  medicine,  in  eight  books,  Latin  and 
English.  Translated  from  L.  Tarja's  edition,  by  Alexander  Lee,  London,  1831, 
also  by  James  Grieve  and  George  Futvoye,  London,  1837.  A  translation  of  the 
eight  books  of  Aul.  Corn.  Celsus  on  medicine,  3d  ed.,  by  G.  F.  Collier,  M.D.,  Lon- 
don, 1843.     Book  v.,  cap.  xxvi.,  187.     Book  VII.,  cap.  xix.,  299. 

4.  A.D.  360.  Oribasius  IwayuyallaTpiKal,  oevivres  d'Oribase,  par  Bussemaker  et 
Daremberg,  Paris,  1851-62.  Gra3corum  chirurgici  libri,  etc.,  editi  ab  Antonio 
Cocchio,  Florentite,  1774.  Oribasii  cap.  xiii.,  de  amputandis  partibus  ex  Archi- 
gene,  p.  155.     Cap.  xiv. ,  Heliodori  de  extremis  membris  abscindendis,  p.  156. 

5.  1st  and  2d  Cent.  Analecta  historico-medica  de  Archigene  medico  et  de 
Apolloniis  medicis,  etc..  Lips.,  1816.  4.  C.  F.  Harless. 

6.  1st  and  2nd  Cent.  De  Heliodori  veteris  chirurgi  fragmentis.  Diss.  Gryphiso, 
1846.  8.  T.  Lenz. 

7.  3d  Cent.  Claudii  Galeni  opera  omnia.  Ed.  Kuhn,  Lipsiye,  1827-30,  De 
Methodi  Medendi  V.,  cap.  iii.,  p.  378. 

8.  6th  Cent.  Aetms  jSiftMa,  la-fUKd  tKKaiSeiia.  The  works  of  Aetius  translated 
into  Latin  hj  Cornarus  and  Montanus,  Basil,  1533-35,  fol.  p.  47  (a  quotation  from 
Rufus). 

9.  7th  Cent.  The  seven  books  of  Faulus  ^gineta.  Translated  from  the  Greek, 
etc.,  by  Francis  Adams,  London,  1846.     Sj'denham  Soc,  pp.  130,  128. 

10.  10th  Cent.  Abubetri  Rhazte  Maomethi  liber  continens  Basilese,  1544, 
Lib.  I.  VII.,  de  fluxione  sanguinis  ex  vulneribus. 

11.  10th  and  11th  Cent.  Avicenna.  Arabum  medicorum  principis  ex  Gerardi 
Cremonis  versione,  et  Andrete  Alpagi  Bellumensis  castigatione.  Per  Fabium 
Paulinum  Venetiis  apud  Juntas,  1595. 

12.  12th  Cent.  Averrhoes.  Liber  de  medicina  64  ff . ,  fol,  Venetiis,  1490,  also 
Avenzohar,  of  same  place  and  date. 

13.  12th  Cent.  Avenzoliar  (ablumieron)  incipit  liber  theicrisi  dahalmodana 
vahaltadabir,  etc.  per  Joanneni  de  Forlivio  et  Gregorius  fratres.  Anno 
salutis,  mcccclxxxx. 

14.  12th  Cent.  Albucasis  de  chirui'gia,  arabice  et  latine.  Cura  Johannis 
Channing-,  Oxford  Clarendon  Press,  1778.  La  chirurgie  d'Abulcasis,  Traduction 
frangaise  du  Dr.  L.  Leclerc. 

15.  13tli  Cent.  Averrhoes,  Incipit  liber  de  medicina  Aneroys  cjui  dicitur  Coli- 
get,  etc.,  anno  1482,  impr.  Veneciis  per  Laurent  de  Valentia  et  socios. 

16.  1295-6.  Lanfranclii's  surgerj^  also  Lanfranci.  Practica  qua^  dicitur  ars 
completa  totius  cliirurgia^.     Venet.,  1490  f.,  also  Coll.  Chir.  Ven.,  1519. 

17.  1363.  Cj'rurgia  Guidonis  de  Cauliaco  et  Cyrurgia  Bruni,  Feodorici,  Ro- 
landi,  Lanfranchi,  Rogerii,  Bertapalie  Venetijs  per  B.  Venetum  de  Vitalibus, 
1519. 

18.  1450.  Leonardo  Bertaplagia.  Cyrurgia  S.  RecoUectas  sviper  quarto  Avi- 
cenntc.     Venet,  1498,  de  vulneribus,  c,  20. 

19.  1497.  Dis  ist  das  buch  der  Cirurgia,  Hautwurckung  der  Wundartzney 
von  Hieronymus  Braunschweig.  Augsburg,  also  English  translation  London,. 
1525. 

20.  1506.     Angelus  Bolognini.     De  cura  ulcerum  exteriorum.     Venet. 

21.  1514.  Marianus  Sanctus  de  Bai-letta  (s,  Barolitamus)  compendium  in 
Chirurgia  (Rom  ?). 


164  The  Ligature  of  Arteries. 

23.  1543.  Johannis  Tagaultius.  De  chirurgica  institutione  libri  quinque. 
Paris. 

23.  1553.  Alph.  Terrius.  De  Sclopetorum  sive  Archibusorum  vulneribus  libri 
tres,  etc. 

34.  1575.  Les  oeixvres  de  M.  Ambroise  Pare  avec  les  figures  et  portraicts  tant 
de  Taiiatomie  que  des  instruments  de  chirurgie  et  de  plusieurs  nionstres.  Paris, 
1575,  1579,  1585,  1598,  etc.     ii.,  334. 

Ambroise  Pare.  CEuvres  completes,  revues  et  collationnees  sur  toutes  les 
editions,  par  J.  F.  Malgaigne.  Paris,  1840.  The  works  of  Ambrose  Parey, 
London,  1691,  306. 

25.  1613.     Jacques  Guillemeau.     Les  oeuvres  de  chirurgie.     Paris. 

36.  1653.  Wilhelm  Fabriz  von  Hilden.  Wundarzneikunst.  Frankfort  a.  M. 
(Wilhelni  Fabry  of  Hiklen  or  Fabricivis  Hiklauus). 

37.  1660.     Leonardi  BotaUi.     Opera  omnia,  Lugduni  Batavorum,  p.  790. 

38.  1073.  Richard  Wiseman.  A  Treatise  of  wounds,  also  experiments  made  at 
London  for  stauncliing  the  blood  of  arteries  and  veins.  Phil.  Trans.  Apr.  ii.,  17, 
1673. 

39.  1674,     Morel.     Mem.  de  Tacad.  roy.  de  Chir.  ii.,  390. 

30.  1684.  Coruelis  van  Solingen.  Manuale  operative  der  Chirurgye.  T'  Am- 
sterdam. 

31.  1703.  Barthel^my  Saviai-d.     Nouveau  recueil  d'observations  chirurgicales. 
33.  1707.  Pierre  Dionis.     Cours  d'op6rations  de  chirurgie  demontrees  au  Jar- 
din  duRoi.  Paris. 

33.  1718.     Loi'enz  Heister.     Cliirurgie.     Nuremberg. 

34.  1730.     R.  J.  Garengeot.     Traits  des  operations  de  chu-urgie.     Paris. 

35.  1731.  Jean  Louis  Petit.  Dissertation  sur  la  maniere  d'arreter  le  sang  dans 
les  hemorrhagies.    Memo,  de  I'acad.  rovale  dessci.     Paris,  also  ibid.  1733  and  1735. 

36.  1734.  Alexander  Monro.  Reniarks  on  the  coats  of  the  Arteries,  their 
diseases,  and  particuhirlv  on  the  formation  of  an  aneurism.  Med.  Essays  and  Obs. 
Edinb.,  ii.  364. 

37.  1736.  Francois  Sauveur  Morand.  Sur  les  changements  qui  arrivent  aux 
arteres  couples,  ou  Ton  fait  voir  (ju'ils  contribuent  essentiellement  a  la  cessation 
des  hemorrhagies.     M6m.  de  TAcad.  roN'ale  des  sci.,  Paris. 

38.  1739.  Samuel  Sharp.  A  treatise  on  the  operations  of  surgerj',  etc.  Lon- 
don. 

39.  1743.     Henri  Francois  Ledran.     Traits  des  operations  de  chirurgie.     Paris. 

40.  1753.  Antoine  Louis.  Seconde  m^moire  sur  Tamputation  des  membres. 
Mem.  de  T  Acad,  i-oyale  de  chii".     ii.,  397. 

41.  1760.     Claude  Pouteau.     Melanges  de  chirurg.     Lyon. 

43.  1763.  Thomas  Kirkland.  Essay  on  the  metliod  of  suppressing  hemorrhages 
from  divided  arteries.     London. 

43.  1770.  Charles  White.  Cases  in  surgery,  with  remarks,  to  which  is  added 
a  treatise  on  the  ligature  of  arteries,  b}-  J.  Aitkin,  London. 

44.  17<r3.     William  Bromfield.     Chirurgica!  observations  and  cases.     London, 

45.  1783.  August  Gottlieb  Richter.  Anfaug.sgrunde  der  Wundarzneikunst. 
Gottingen. 

46.  1793.     Benj.  Gooch.     Chirurgical  works.     London. 

47.  1793.  J.  F,  Louis  Deschamps.  Observations  sur  la  ligature  des  principales 
arteres.     Pans. 

Observations  et  reflexions  sur  la  ligature  des  principales  arteres  blesses.     Paris, 
1797,  33,  53. 

48.  1793.     J.  Aberneth3^     Surgical  and  physiological  essays.     London. 

49.  1794.  John  Hunter.  A  treatise  on  the  blood,  inflammation  and  gunshot 
wounds.     London. 

50.  1798.     Pierre  Joseph  Desault.     CEuvres  chirurgicales.     Paris. 

51.  1799.  Ant341i,  veteris  chirurgi,  ra  leixava  Nicolaides  (Panaiota)  Diss.  Inaug. 
Halis  Magdeb. 

53.  1803.  Jean  Pierre  Maunoir.  M6moires  phj^siologiques  et  pratiques  sur 
Tanevrysme  et  la  ligature  des  arteres.     Paris. 

53.  1805.  J.  F.  D.  Jones.  A  treatise  on  the  process  employed  by  nature  in 
suppressing  the  hemorrhage  from  divided  and  punctured  arteries.     London 

54.  1806,     James  Veitch.     Edinb.  Med.  and  Surg.  Journal,  h.,  176. 


Bibliography.  1 6  5 

55.  1812.  M^moires  de  medecine  et  de  Chirurgie  militaire  et  de  Campagnies 
de  J.  D.  Larrey.      Paris. 

56.  1815.  Joseph  Hodgson.  A  treatise  on  the  diseases  of  arteries  and  veins, 
containing  the  pathology  and  treatment  of  aneurisms  and  wounded  arteries,  xix, 
Loudon.     T.  Underwood. 

57.  1815.  John  Bell.  Principles  of  Surgery,  London,  i.,  141.  Discourse  on  the 
Nature  and  Cure  of  Wounds.     1800,  p.  109! 

58.  1817.  Anton  Scarpa.  Memoria  sulla  ligatura  delle  principale  arterie. 
Pavia. 

59.  1818.  Johann  Friedrich  Meckel.  Handbuch  der  palhologischen  Anatomic, 
ii.,  Leipsig. 

60.  1819.     Crampton.     Med.  Chir.  Trans,  vii. 
61.1819.     Travers.     Med.  Chir.  Trans.,  vi.,  632. 

62.  1831.  Balthasar  Antlielme  Richerand.  Nosographie  et  thei'apeutique 
chirurgicales,  Paris. 

63.  1823.  Delpech.  Chirurgie  clinique  de  Montpellier,  i.,  109.  Paris  et  Mont- 
pellier. 

64.  1824.     Boullaud.     Archives  g6n.  de  m6d. 

65.  1824.  Cooper  (Sir  Astley  Paston)  Lectures  on  the  principles  and  practice 
of  surgery,  with  additional  notes  and  cases  by  P^rederick  Tyrrell.     London,  1824-27. 

66.  1825.     Ribes.     Revue  medicale  francaise  et  etrangere,  iii. 

67.  1825.  C.  J.  M.  Langenbeck.  Nosologic  und  Therapie  der  chirurgischen 
Krankheiten.     Gottingen,  iii.,  134. 

68.  1826.  Ebel.  De  natura  medicatrice  sicubi  arterije  vulnerata^  et  ligatse 
fuerint  Giessen. 

69.  1826.     Vatel.     Sur  le  thrombus  et  la  phlebite  pai-tielle.     Joui".  prat,   de 

Koch  Jovunal  von  Grafe  und  Waltlier,  ix.,  560,  Berlin. 
Gendrin.     Histoire  anatomique  des  inflanuuations,  ii.,  Paris. 
Holtze.     Diss,  de  arteriariim  ligatura,  Berlin. 
Rigot  et  Trousseau.     Archives  g^nerales,  Paris,  xiv. 
Sciionberg'.     Journal  des  progres.     Paris,  xii.,   70. 
A,  Thierry.     De  la  torsion  des  arteres,  Paris. 

J.  F.  Lobstein.       Traits  d'anatomie  pathologique  gen^rale  et  spe- 
ll. S.  Levert.     Experiments  on  the  use  of  metallic  ligatures  as  ap- 
plied to  arteries.     Am.  Jour.  M.  Sci.  iv.,  17,  23. 

78.  1829.     Henry  Levert.     Journ.  von  Grafe  und  Walther,  xiii.,  561. 

79.  1830.  Beclard.  Recherches  et  experiences  sur  les  blessures  des  arteres. 
Mem.  de  la  soc.  med.,  viii. 

80.  1830.  G.  J.  Guthrie.  Diseases  and  Injuries  of  the  arteries.  Wounds  and 
injuries  of  arteries,  London,  1846. 

81.  1830.     Blandin.     Journal  hebd.  de  m6d.,  Paris,  Mai. 

82.  1830.  Andral.  Precis  d'anatomie  pathologique.  Bruxelles,  ii.,  59,  71.  76, 
77. 

83.  1830.  "Velpeau.  Jour,  universelle  et  Hebd.  i.,  no.  5.  Nouveaux  elements  de 
medecine  operatoire,  Paris,  1832. 

84.1830.     C.  A.  C.  Schrader.     De  torsione  arteriarum.     Berolini,  1831 . 

85.  1831.  Dietrich.  Das  Aufsuchen  der  Schlagadern.  behufs  unterbindung, 
etc.     Niirnbvirg.     333. 

86.  1831.  Pegot.  Observations  et  reflexions  svir  la  torsion  des  arteres.  J. 
univ.  et  hebd.  de  med.  et  de  chir.  prat.,  Paris,  v.  229. 

87.  1831.  Bujalski.  Journal  v.  Grafe  und  Walther,  xv.,  402  ibid.  P6got  iv., 
461,  ibid  Uso  Walter  xvi.,  355. 

88.  1831.  Buet.  Nouveaux  fails  sur  la  torsion  des  arteres  et  sur  le  refoule- 
ment  de  leurs  meiubranes.     J.  compl.  de  diet.  d.  sc.  med.  Paris,  xli.  282. 

89.  1831.  B6dor.  Observations  et  reflexions  sur  la  torsion  des  arteres.  Gaz. 
d.  hop.,  Paris,  vi.,  46. 

90.  1832.     Dupuytren.     Legons  orales  de  clinique  chinu-gicale,  Paris. 

91.  1832.     Manec.     Traite  de  la  ligature  des  arteres,  Paris. 

92.  1832.  Uso  Walther.  Untersiichungen  liber  die  temporaren  Unterbindun- 
gen  der  Arterien,  etc.     Journal  von  Graei'e  und  W^alther,  xvi. 


med.  ' 

veterin, 

70. 

1826. 

71. 

1826. 

72. 

1827. 

73. 

1827. 

74. 

1828. 

75. 

1829. 

76. 

1829. 

dale, 

Paris. 

77. 

1829. 

1 66  The  Ligature  of  Arteries. 

93.  1833.     B.  B.  Bamberger.     De  ^^ariis  torsionis  arteriarum  methodis,  Bei'olini. 

94.  1833.     T.  Brockmuller.     De  arteriarum  toi'sione,  Bonnae. 

95.  1834.  Rust.  Theoretisch-practisches  Handbuch  der  Chirurgie.  Berlin 
und  Wien.  xv.,  206,  209. 

96.  1834.  W.  Youatt.  On  the  torsion  of  arteries  to  arrest  hemorrhage  in  veter- 
inary operations.     Lancet,  London,  ii.,  386. 

97.  1834.  Cruveilhier.  Anatomie  pathologique.  Maladies  des  veines  et  des 
arteres,  Paris. 

98.  1834.  B.  Stilling.  Die  Bildung  imd  Metamorphose  des  Blutepfropfes  oder 
Thrombus  in  verletzten  Gefassen,  Eisenach. 

99.  1835.  D.  Van  Dockum.  QuEcnam  mutationes  pathologicEe  inducuntur 
arteriis  per  ligaturam.     Ann.  Acad.  Rheno-Traject.,  1-73. 

100.  1839.  Stannius.  Ueber  krankhafte  Verschliessung  grosserer  Venen- 
stamme. 

101.  1840.  Remak.  V.  Amnion's  Monatsschrift  flir  Medicin,  Augenheilkunde 
und  Chirurgie,  iii. 

102.  1840.  Nicolaus  Pirogofif.  Ueber  die  Durchschneidung  der  Achillessel me, 
Dorpat. 

103.  1841.     Hasse.     Specielle  pathologische  Anatomie,  Leipzig. 

104.  1843.  Tiedemann.  Von  der  Verengerung  und  Schliessung  der  Pulsadern 
in  Krankheiten,  Heidelberg. 

105.  1843.     Vogel.     Pathologische  Anatomie,  102.    Leipzig. 

106.  1844.  Carl  Rokitansky,  Handbuch  der  pathologischen  Anatomie.  Wien. 
also  1856,  ii.,  350. 

107.  1844.  Amussat,  Gazette  medicale  de  Paris.  No.  44, 1845,  No.  25.  Archives 
Gen.  de  M6d.  Aout.  1829,  xx.  Recherches  experimentales  sur  les  blessures  des 
arteres  et  des  veines.  1843. 

108.  1845.  Vu-chow.  Ueber  den  FaserstofT.  Ges.  Ablidlg.  1845,  1846,  1855. 
Med.  Zeit.  des  Vereins  fiir  Heilk.  in  Preussen,  1847,  Sept.  Literar.  Beilage  No.  35. 
Ai-chiv.  f.  Path.  Anat.  i.,  272,  1847,  Wiirzburger  Verhandluugen  185i,  ii.,  315. 
Gesam.  Abhdlg.  zur  wis.  Med.  Frankfort  a  M.,  1862. 

109.  1845.  Luigi  Porta,  Delle  alterazione  pathologiche  delle  arterie  per  la 
legatura  e  la  torsione,  Milano.  Delle  ferite  delle  arterie,  1852.  Ann  de  th^rap. 
No.  7,  1847. 

110.  1845.     H.  Zwick}'.     Die  Metamoi-phose  des  Thrombus,  Zurich. 

111.  1846.     J.  Lisfranc.     Precis  de  medecine  operatoire,  ii.,  791,  Paris. 

112.  1851.  Reinhardt.  Ueber  die  Metamorphose  faserstoffiger  Exsudate. 
Deutsche  Klinik,  No.  36,  also,  Patholog.  anatoui.  Untersuchungen,  herausg. 
von  Leubuscher,  Berlin,  1852,  42. 

1^  113.  1851.  Notta.  Observation  pour  servir  a  1'  histoire  de  la  pathologie  du 
caillot,  qui  se  forme  dans  les  arteres  a  la  suite  de  leur  lig-ature.  Gaz.  d.  Hop.,  Par. 
8,  5,  iii.,  174,  also  Recherches  sur  la  cicatrisation  des  arteres  a  la  suite  de  leur 
ligature.  Gaz.  med.  de  Par.,  1850,  3,  s.  v.,  870 ;  also  Ann.  de  Med.  beige.,  Brux., 
1850,  iv.,  413,  1851,  i.,  122,  ii.,  119  ;  also  Memoire  svir  I'obliteration  des  arteres  om- 
bilicales,  et  sur  I'art^rite  ombilicale  Mem.  de  1' Acad.  Imp.  de  M6d.  xix.,  1855, 
Paris,  also,  Mem.  Soc.  de  Chir.  de  Par.  1857,  iv.,  477. 

114.  1851.  J.  Piernas.  Experiments  with  the  ligature  on  animals.  N.  Orl. 
M.  &S.  Jour,  viii.,481. 

115.  1851.  Gerstacker.  De  regeneratione  tendinum  post  tenotomiam,  Bero- 
lini. 

116.  1851.  Feigel  (J.  T.  A.)  Chirurgische  Bilder  zur  Instrumenten  und  Opera- 
tions Lehre,  vollendet  von  Textor,  Wiirtzburg. 

117.  1852.  Henrj'  Lee.  Medico-Chirui-gical  Transactions.  Lee  and  Beale, 
ibid.,  1867. 

118.  1852.     Thierf elder.     De  regeneratione  tendinum. 

119.  1853.  Risse.  Observationes  qutedam  de  arteriarum  statu  normali  atque 
pathologico,  Regiomont. 

120.  1854.  Butcher,  On  wounds  of  arteries  and  their  treatment.  Dublin  Quai'- 
terlj'  Journal,  Avig. 

121.  1854.    Boner,  Die  Regeneration  der  Sehnen.    Archi v.  f.  patholog.  Anat., ix. 

122.  1857.  E.  Briicke,  Ueber  die  Ujsache  der  Gerinnung  des  Bhites.  Archiv. 
f.  patholog.  Anat.,  xii. 


Bibliography,  167 

133.  1858.  C.  A.  Gayet.  Nouvelles  recherches  experimentales  sur  la  cicatri- 
sation des  avteres  apres  leur  ligature,  Paris. 

124.  1858.  Robin.  Bulletins  d<!  TAcademie  de  Med.  also  59.  M^moii-e  sur  le 
retraction,  la  cicatrisation  et  Finflammation  des  vaisseaux  onibilicaux.  M6ni. 
de  r  Acad.  Imp.  de  M6d.  xxiv. ,  Paris. 

135.  1859.  C.  Rauchfus.  Ueber  Tlu'ombose  des  ductus  arteriosus  Botalli. 
Archiv.  f.  path,  anat.,  Berlin. 

136.  1859.  L.  Buhl.  Einige  Falle  von  Thrombose  und  Bemerkungen  iiber 
Atheromatose.     Wiener  Med.  Wochenschrift,  No.  34. 

137.  1860.  J.  Dix.  On  the  advantages  of  acupressure  over  the  ligature. 
Med.  Times  and  Gazette,  London,  i.,  546.  On  the  wire  compress  as  a  substitute 
for  the  ligature.     Edinb.  Med.  Jour.,  x.,  307-319. 

138.  1860.     Cohn.     Klinik  der  embolischen  Gefasskrankheiten,  Berlin. 

139.  1860.  J.  Y.  Simpson.  Acupressure,  a  new  method  of  arresting  surgical 
hemorrhage.  Edinb.  M.  Jour,  v.,  645.  Med.  Times  and  Gazette,  London,  1860, 
i,,  137,  1864  n.  s.  i.,  1,  35  ;  33,  81,  141.  Did  John  de  Vigo  describe  acupressure 
in  the  sixteenth  century?  Brit.  M.  J.  1867,  ii.,  145;  also  paper  dated  1860,  also 
1867. 

130.  1860.  D.  Wachtel.  Neues  Verfahren  Zur  Hemmung-  der  Blutung",  etc. 
Ztschr.  f.  Nat.  u.  Heilk.  in  Ungarn.     Oldenburg,  xi.  121. 

131.  1861.     Oilier.     Gaz.  Hebd.  de  Med.  et  Cliir.,  135. 

133.  1861.     L.  H.  Jackowitz.     Ueber  die  Acupressur  der  Arterien,  Dorpat. 
133.  1861.     Honisch.     Historische  Nachweis  fiir  das  hohe  Alter  der  Arterien- 
Torsion.     Allg.  Wien.  Med.  Ztg.,vi.,125. 

134.1863.     N61aton.     Gaz.  des  Hopit.,  146. 

135.  1863.     E.  Lanceraux.     Gaz.  M6d.  de  Paris,  No.  44. 

136.  1863.  V.  Recklinghausen.  Ueber  Eiter  und  Bindegewebskorperchen. 
Arch,  fiir  patholog.  Anat.  etc.,  Berlin,  xxviii.,  157. 

137.  1863.  Theodor  Billroth.  Die  allgemeine  chirurgische  Patliologie  und 
Therapie,  Berlin,  1863  etc.,  Billroth's  Surgical  Pathology,  New  York,  1871, 
Berlin,  Klin  Woch.  1871,  Chirurgische  Briefe  aus  den  Kriegslazarethen,  Berlin, 
1873. 

138.  1864.     Holt.     Lancet,  July  33. 

139.  1864.  C.  O.  Weber.  Ueber  die  Vascularisation  des  Thrombvis.  Berlin 
Klin.  Woch.,  1864.  Handbuch  der  Allg." und  spec.  Chir.  von  Pitha  und  Billroth 
Bd.  1,  141,  Erlangen,  1865. 

140.  1865.     W.  Pirrie.     On  acupressure.  Med.  Times  and  Gaz.,  London,  ii.,  5. 

141.  1865.  R.  L.  Tait.  On  the  results  of  temporarv  metallic  compression  of 
arteries.  Med.  Times  and  Gazette,  London  ii.,  57,85,1866,1,  197;  335,  1867,  i, 
333.     Letter  on  ligature,  acupressure  and  torsion.     Lancet,  London,  i.,  695,  1869. 

143.  1865.  August  Foerster.  Handbuch  der  speciellen  pathologischen  Ana- 
tomic, Leipzig,  ii.,  737. 

143.  1866.     His.  Die  Haute  und  Hohlen  des  Korpers.  Basel. 

144.  1866.  E.  Rindfleisch.  Lehrb.  der  patholog.  Geweblehre,  Leipzig,  1873, 
1875. 

145.  1867.  E.  Celestin.  Recherches  sur  les  alterations  des  arteres  a  la  suite 
de  la  ligature,  Paris. 

146.  1867.  E.  F.  Cocteau.  Recherches  sur  les  alterations  des  arteres  a  la 
suite  de  la  ligature,  Paris. 

147.  1867.  B.  Howard.  Interesting  experiments  with  ligatures.  Med.  Rec. 
N.  Y.,  1867,  ii..  449. 

148.  1867.     Porter.     Dublin  Med.  Journal,  269. 

149.  1867,  N.  Bubnoff.  Ueber  die  Organization  des  Thrombus.  Centralblatt. 
f.  die    Med.  Wiss.  No.  48.     Arch.  f.  path.^Anat.  xliv.,  1868. 

150.  1867.  C.  Thiersch.  Die  feineren  anatomischen  Veranderungen  nach 
Vemvundung  der  Weichtheile.  Handbuch  der  allgenieinen  und  speciellen  Chir- 
urgie  von  Pitha  und  Billroth,  i.,  531,  Erlangen. 

151.  1867.  Simbert.  Compt.  rendus  des  Sci.  et  Mem.  de  la  Soci^te  de  Biologic, 
Paris. 

153.  1867.     G.  W.  Callender.     Note  on  acupressure.  Lancet,  i.,  597. 
153.  1867.     Conheim.     Arch.  f.  Path.  Anat.  xl.,  1 ;  also  Lectures  on  General 
Pathology. 


1 68  TJie  Ligature  of  Arteries. 

154.  1867.  Waldever.  Zur  pathologischen  Anatomie  der  Wundkrankheiten, 
Arch.  f.  Path.  Anat,  xl.,  391. 

155.  1867.  Henry  Lee  and  Lionel  S.  Beale.     Medico-Chirurg-.  Trans.,  i. 

156.  1868.  T.  G.  Morton.  Review  of  the  ligature  of  arteries  at  the  Penn. 
Hosp.  Penn.  Hos.  Rep.,  i.,  192  ;  also  Am.  J.  M.  Sci.,  1876,  n.  s.  Ixxi.,  334,  Jxxii. 
17. 

157.  1868.  Hutchinson.  The  effect  of  acupressure  on  arteries,  Med.  Rec,  N 
Y.  ii.,  544. 

158.  1868.  A.  Hewson.     On  acupressure.     Penn.  Hos.  Rep.  Phila.  i.,  127. 

159.  1868.  Thos.  Brvant.     Medico-Chir.  Trans.,  xli. 

160.  1868.  Czernay.^    Centralblatt  f.  die  Med.  Wissen.,  No.  1. 

161.  1868.  Max  Broer.  Untersuchungen  tiber  die  Organisation  und  Zerfall 
des  Thrombus.     Inaug.  Diss.,  Breslau. 

162.  1868.  J.    H.  Pernet.       De  I'acupressure  comnie  moyen  hemostatique, 

163.  1869.  T.  Walkloff.  Das  Gewebe  des  Ductus  Arteriosus  und  die  obJit.  des- 
selben,  Ztschr.  f.  Rat.  Med.     Leipzig,  xxxvi.,  3  R.  109-131,  2  pi. 

164.  1869.  Pelecliin.  Studien  fiber  den  Einfluss  der  entfernten  Unterbindung 
von  Hauptarterienstammen  auf  die  entsprechende  Capillar,  und  Venen  circula- 
tion.    Archiv.  fiir.  path.  Anat.,  Berlin,  xlv.,  417. 

165.  1869.  Tschausoflf.  Ueber  den  Thrombus  bei  der  Ligatur.  Arch.  f.  klin 
Chir..  xi.,  184. 

166.  1869.  Theodor  Kocliei".  Ueber  die  feineren  Vorgange  bei  der  Blutstillun- 
gen  durch  Acupressur,  Ligatur  und  Torsion.  Arch.  f.  klin.  Chir.,  xi.,  660. 

167.  1869.  Richardson,  Med.  Times  and  Gazette,  April  24. 

168.  1869.  G.  A.  Peters.  An  essaj'^  on  acupressure  with  reference  to  its  appli- 
cation in  the  continuity  of  arteries.  N.  Y.  M.  J.,  ix.,  225. 

169.1869.     Oa-ston.     Lancet,  April  17. 

170.  1869.     Pollock.     New  York  Med.  Jour. 

171.  1869.  G.  M.  Hunijihrey.  On  Torsion  of  arteries,  with  an  account  of  some 
experiments.     Brit.  Med.  Jour.,  London,  i.,  502. 

172.  1870.  F.  Rizzoli.  Sulla  agopressiono  in  ispecie  pettrallamento  d'alcune 
particolari  cisti  aneurismaticho,  Mem.  Acad.  d'Sci.  d.  Inst,  di  Bologna,  2,  s,  x.  555. 

173.  1870.  Prengrueber.  Sur  I'acupressure  dans  letraitement  des  anevrysmes 
externes — Priorite  des  travaux  du  professeur  Rizzoli  (de  Bologne)  sur  ceux  de  Simp- 
son (d'Edinbourg)  Gaz.  hebd.  de  med.,  Paris,  2s.,  vii.,  420. 

174.  1870.  L.  Ranvier.  Epithelium.  Nouveau  Diet,  de  M6d.  et  de  Chir. 
pratique. 

175.  1870,  Roser.  Archiv.  Zur  Theorie  der  Blutstillung,  Arch.  f.  Klin.  Chir., 
xii.,  1870. 

176.  1870.  S.  Strieker.  Ueber  die  Zelltheilung  in  entziindeten  Geweben, 
Studien  aus  dem  Institute  f.  e.xperimentelle  Path.,  Wein.  Vorlesungen  iiber 
allgemeinen  und  experimentellePath.,  ii.,  1878.,  Wein.  Inter.  Encyc.  Surg.,  i.,  1883. 

177.  1871.     R.  Mayer.  Leiirbuch  der  allg.  path.  Anat.,  Leipzig,  23. 

178.  1871.  Hanns  Kundrat.  Ueber  die  krankhaften  Veranderuugen  der  Endo- 
thelien.  Wein,  Med.  Jahrb.,  ii. 

179.  1871.  Ercolani.  Del  processo  anatomico  di  obliterazione  delle  arterie  e 
della  Vena  ombiliuale.     Mem.  d.  Acad.  d.  sci.,  d'  Inst,  de  Bologna,  i. 

180.  1871.  F.  Durante.  Untersuchungen  ueber  die  oi'ganization  des  Thromb. 
Wiener  Med.  Jahrb.,  1872,  143.  Untersuchungen  ueber  Entziindung  der  Geffiss- 
wande,  ibid.  1871.  321.     Arch,  de  Physiologic,  1872. 

181.  1872.  Albert  Adamkiewicz.  Die  mechanischen  Blutstillungsmittel  bei 
verletzten  Arterien  von  Pare  bis  auf  die  neueste  zeit.  Arch.  f.  klin.  Chir.,  xiv. 

182.  1872.  Dudukaloff.  Bertrage  zur  Kenntniss  des  Verwachsungsprocesses 
unterbundener  Gefasse,  Wiener  Med.  Jahrb.  ii. 

183.  1872.  C.  A.  Hart.  Successful  application  of  Dr.  Speirs*  arterv  constrictor. 
N.  Y.  Med.  Jour,  xv.,  175-183;  see  also  Tr.  Med.  Soc,  N.  Y.  Albany,  1871,  269, 
284. 

184.  1873.     Cornil  et  Ranvier.     Manuel  d'histologie  pathologique,  Paris. 

185.  1873.     E.Klein.     Anatomy' of  the  lymphatic  system. 

186.  1873.  J.  B.  Ullersperger.  Geschichtliche  Berichtigungen  fiber  torsio 
arteriaruni.     Bl.  f.  Heihvissensch,  Mlinclien,  iv.,  17. 


Bibliography.  169 

187.  1874.  Nicolaus  Strawinsky.  Ueber  den  Ban  der  Nabelgefasse  und  iiber 
ihrea  Verschluss  nach  der  Geburt.  Sitzungsberichte  der  kaiserl.  Acadauiie  der 
Wissenseliatten,  Ixx.,  Weia. 

188.  1874.     O.  Heubner.     Die  luetische  Erkrankving"  der  Hirnarterien,  Leipzig. 

189.  1874.  L.  Sznnian.  Untersuchmigen  fiber  den  temporaren  und  daiiernden 
Verscliluss  der  Gefass  lamina  nach  Unterbindung  und  Acupressur,  Memoiren  des 
Vereins  russisclier  Aertze.  Gekronte  Preisschrift  der  Breskiuer  Facultat.  Central- 
bkatt  f.  d.  Med.  Wiss.,  1874,  No.  49. 

190.  1875.  G.  C.  E.  Weber.  A  new  method  of  arresting  liemorrhage.  Med. 
Rec.  N.  Y.  X.,  305. 

191.  1875.  V.  Czerny.  Ein  Aneurysma  varicosum.  Ein  Beiti*ag  ziu-  Leln-e 
von  der  Organisation  geschichteter  Thromben.     Arch.  f.  patli.  Anat.  Ixii.,  464. 

192.  1875.  B.  Riedel.  Die  Entwickeking  der  Narbe  im  Bkitgefass  nach  der 
Unterbindung.     Deutsche  Zeitschrift  fiir  Chirurgie,  vi.,  459. 

193.  1875.  Paul  Bruns.  Die  temporare  Ligatur  der  Artej-ien  nebst  einem 
Anhange  iiber  Lister's  Catgutligatur.     Zeitsclirift  f.  Chir.  v.,  379. 

194.  1875.  F.  Wilhehii  Zalui.  Untersucliungen  iiber  Thrombose.  BikUmg 
der  Thromben,  Arcli.  f.  path.  Anat.  Ixii.,  81,  ibid.  Ixix.,  1884. 

195.  1875.     C.  F.  Maunder.     Lancet.    Lectures. 

196.  1875.  A.  Verneuil.  De  la  forcipressure.  Bull,  et  Mem.  Soc.  de  Chir. 
de  Paris,  n.  s.  137. 

197.  1875.  Heinricli  Haeser.  Lehrbucli  der  Gescliichte  der  Medicin  und  der 
epidemischen  Kranklieiten,  Jena. 

198.  1875.  Koster.  Ueber  die  Structur  der  Gefasswiinde  und  die  Entziindung 
der  Venen.  Berliner  khn.  Woch.  No.  43.  Ueber  Endarteritis  und  Arteritis. 
Berliner  klin.  Woch.  1876,  No.  23. 

199.  1876.  Discussion  du  memoire  de  M.  Tillaux  sur  la  torsion  des  arteres. 
Bull,  et  Mem.  Soc.  de  Chir.  de  Par.,  n.  s.  ii.,  277.     Tillaux,  ibid.,  231. 

200.  1S76.  Paul  Baumgarten.  Ueber  die  sogenannte  Organisation  des  Throm- 
bus, Centralb.  i.  d.  med.  Wiss.,  No.  34.  Reprint  1877,  Uber  das  offenbleiben  fotaler 
Gefasse,  Centlb.  d.  Med.  Wis.,  No.  41.,  1877. 

201.  1876.  Friedlander.  Ueber  Arteriitis  obliterans.  Centralb.  f.  d.  medic. 
Wiss.,  No.  4. 

202.  1876.  R.  McDonnell.  Torsion  of  Arteries.  Med.  Press,  and  Circ,  Lon- 
don, i.,  153. 

203.  1876.  C.  Faget.  Obliteration  of  the  Botal  foramen  and  ductus  arteriosus. 
N.  Orl.  M.  &  S.  J.,  iv.,  29-36. 

204.  1876.  Ernst  Ziegler.  Untersucliungen  iiber  pathologische  Bindegewebs 
und  Gefassneubiklung,  Wlirzburg. 

205.  1877.  Benjamin  Auerbach.  Ueber  die  Obliteration  der  Arterien  nach 
Ligatur,  Diss.  Bonn. 

206.  1877.  Nadieschda  Schultz.  Ueber  die  Venarbung  von  Arterien  nach 
Unterbindungen  und  Vervvundungen.     Diss.  Leipzig. 

207.  1878.  F.  V.  Winiwarter.  Endarteritis  und  Endophlebitis.  Arcliiv.  f. 
klin.  Chir..  23. 

208.  1878.  Fritz  Raab.  Ueber  die  Entwickelung  der  Narbe  im  Blutgefass 
nach  der  Unterbmdung.  Arch.  f.  klin.  Chir.,  xxiii.,  156;  also  Arch.  f.  Patli.  Anat., 
Ixxv.,  451-471.     Berlin. 

209.  1879.  F.  Ferriei'e.  Historical  researches  on  the  ligature.  St.  Louis  Clin. 
Rec.  vi.,  325. 

210.  1879.  M.Ramos.  Estudio coiiiparativo entre la foi'cipressura  etc.  Escula 
de  Med.  Mexico,  i..  No.  xiii.,  etc. 

211.  1879.     Pfitzer.     Archiv.  f.  Path.  Anat.,  Sept.  24. 

212.  1879.  Senttleben.  Ueber  den  Verschluss  der  Blutgefasse  nach  der  Unter- 
bindung.    Archiv.  f.  Path.  Anat.,  Berlin,  Ixxvi.,  421. 

213.  1879.  Edwai'd  O.  Shakespeare.  The  nature  of  reparatory  inflammation 
in  arteries  after  ligature,  acupressure,  and  torsion.  The  Toner  Lectures,  Wash- 
ington.    Allen's  Human  Anatomy-,  Philadelphia,  1883. 

214.  1880.  Arnaud.  Contribution  k  I'etude  de  la  ligatvu'e  dans  le  traitement 
des  anevrisms.  Paris. 

215.  1880.  J.  Boeckel.  De  la  ligature  antiseptique  des  gros  troncs  arteriels 
dans  la  continuite.     Rev.  Med.  de  Test.     Nancy,  xii.,  203. 


170  TJie  Ligatiire  of  Arteries. 

216.  1880.  L.  M.  Reuss.  De  la  ligature  antlseptique  cles  gros  troiics  arteriels. 
Jour,  de  therap.,  Paris,  vii.,  542. 

217.  1881.     Servier.     Deligation.     Diet,  encycl.  de  sci.  Med.,  Paris. 

218.  1881.  F.  Treves.  A  case  illustrating  the  condition  of  large  arteries  after 
lig-ature,  etc.     Proc.  Roy.  M.  &  Chir.  Soc,  London,  ix.,  25. 

219.  1881.  C.  W.  F.  Uhde.  Unterbindung  von  Arterien  in  der  Continuitat. 
Arch.  f.  klin.  Chir.  Berlin,  xxvi.,  840. 

220.  1881.     C.  T.  Dent.     Med.  Chir.  Trans.,  Ixiv.,  64. 

221.  1881.     John  Ashurst,  Jr.     Encvclopyedia  of  Surgerv,  Vol.  i.,  554. 

222.  1881.  Lister.  Clinical  Societies  Trans.,  xiv  ;  also  Lancet,  1881,  i.,  201, 
275. 

223.  1881-82.  W.  Greifenbei'ger.  Historisch-Kritische  Darstellung  der  Lehre 
von  der  Untei-bindung  Blutgefasse,  Zeitschrift  f.  Cliirurg.,  Leipzig,  xvi. 

~  224.   1883.     T.  Holmes.     British  Med.  Jour.,  June  9. 

225.  1883.     W.  S.  Walsham.     British  Med.  Jour.,  Apr.  7. 

226.  1883.     Thoma.     Arch.  f.  Path.  Anat,  xciii.  and  xcv.,  1884. 

227.  1883.  J.  Black.  On  the  deligation  of  large  arteries  bj^  the  application  of 
two  ligatures  and  the  division  of  the  vessel  between  them.  Brit.  M.  J.,  London, 
i.,  765. 

228.  1888.  Richard  Barwell.  International  Encyclopaedia  of  Surgery,  iii., 
New  York.     Also  Med.  Chir.  Trans.  Ixiv.,  1881. 

229.  1883.  John  A.  Liddell.  International  Enc^'^clopaedia  of  Surgerj-,  iii., 
New  York;  also  Med.  Chir.  Trans.,  Ixiv.,  1881. 

230.  1883.  Wyeth.  Surgical  Diseases  of  the  Vascular  Sj'^stem.  Int.  Encycl. 
Surg.,  iii.,  351  ;  also  Med.  Rec,  N.  Y.,  1882,  xxii.,  103. 

231.  1884.  J.  Collins  Warren.  The  healing  of  arteries  after  ligature.  Pro- 
ceedings Boston  Soc.  Med.  Sci.,  Mar.  20,  1883.  Boston  Med.  and  Surg.  Jour., 
May  1,  1884,  Philadelphia  Med.  Times,  xvi.  132,  1885. 

232.  1885.  N.  Senn.  Cicatrization  in  blood-vessels  after  ligature.  Trans. 
Am.  Surg.  Assoc,  ii.,  Phila. 

233.  1885.  Fr.  Burdach.  Ueber  den  Senftlebenschen  Versuch.  die  Binde- 
gewebsbildung  in  todten,  doppelt  unterbundenen  Gefasstrecken.  betreffend. 
Arch.  f.  Path.  Anat.,  c.  217,  Berlin. 

234.  1886.  Experimentelle  Untersuchvingen  fiber  Thrombose.  J.  C.  Eberth 
und  C.  Schimmelbusch,  Archiv.  f.  Path.  Anat.,  ciii.,  39,  Berlin. 

235.  1886.  William  Osier.  Cartwright  Lectures.  Med.  News,  xlviii.,  690. 
691,  692. 


INDEX. 


Abernethy. 

sanctions  use  of  double  ligature, 
35. 
Acupressure. 

John  tie  Vigo,  6;  Santo,  6. 
proposed  by  Simpson,  37. 
Hewson,  study  of  acupressure,  37. 
effect  as  seen  by  Kocher,  21,  37. 
experiments  by  Shakespeare,  38. 
as  substitute  for  lig-ature,  37,  152. 
changes  found  in  acupressure,  21. 
Acutorsion. 

Kocher's  view  of  its  action,  38. 
experiments  by  Shakespeare,  38. 
adhesive  inflammation  as  suggest- 
ed by  Andral,  12. 
Adventitia. 

infiltrated  with  round  cells,  99. 
Aetius. 

mentions  use  of  the  ligature,  4. 
Alb  ucasis. 

use  of  ligature  and  cautery,  5. 
Alexandrian  School. 

ligature  inti-oduced  bv  surgeon  of, 
2. 
Ampulla. 

"ampulla-like  dilatation,"  55. 
in  carotid  of  horse,  76. 
in  carotid  of  man,  83. 
Bryant,  139. 
Amputation. 

ligature  not  used  in  amputations 

bj'  Romans,  2. 
amputations  avoided  by  successors 

of  Celsus,  3. 
modifications  made  bv  Archigenes, 

3. 
bandages  applied  about  limb  and 
provisional  ligatures  before  am- 
putation, 3. 
brachial  artery  in  stump,  22. 
narrowing  of  arteries  in  stump,  32, 

89. 
appearances  noted  in  vessel  of  am- 
putated stump,  100,  149. 
suiumary  of   experiments  on  am- 
putated stumps,  109. 
experiments     following     amputa- 
tions: 
lacerated  brachial,  98. 
femoral,  99,  104. 
tibial,  99,  100,  102,  103,  104. 
axillary,  100. 
endarteritis  obliterans  tibiae,  106. 


Amussat. 

experiments  on  animals,  14. 
aneurism  in  animals,  14. 
reparative  process  independent  of 

the  ligature,  14. 
more  reliance  should  be  placed  on 

pressure,  14. 
the  first  to  communicate  a  paper 
on  tox'sion,  35. 
Andral. 

believed  in  an  adhesive  inflamma- 
tion of  the  walls  of  the  vessel, 
Aneurism.  [12. 

operation  for  its  cure  invented  by 

Antyllus,  4. 
aneurism      needle      invented     by 

Saviard,  8. 
aneurism  in  dogs  and  horses,  12. 
aneurism  in  animals,  13,  14. 
sac  formed  from  layer  of  fibrine,  29. 
Angelo  Bolognini. 

use  of  silk  ligatures,  6. 
Animals. 

Amussat's  experiments,  14;  Guth- 
rie, 13. 
experiments  on  animals,  47. 
aneurism  in  animals,  13,  14.     [140. 
appearance    of  thrombus  in  dogs, 
Antyllus. 

invents  an  operation  for  the  cure  of 

aneurism,  4. 
advises  use  of  ligature,  4. 
Arabians. 

ligature  rarely  used,  5. 
Archigenes. 

modifications  in  amputations,  3. 
applies  bandag'es  before  amputa- 
tions and  provisional  ligatures, 
3. 
Army    Medical     Museum.     Specimens 

from,  86,  88,  89. 
Arnaud. 

carbolized  catgut  ligatures,  40. 
Arterioles. 

arteriole  in  centre  of  cicatrix,  95. 
Arteritis. 

opinions  of  Cornil  and  Ranvier,  22. 
process  observed  in  traumatic  ar- 
teritis, 20. 
Artery. 

difference    between    arteries    and 

veins,  Praxagoras,  1. 
Rufus  of  Ephesus,  3. 
Claudius  Galenus,  3. 


1/2 


The  Ligature  of  Arteries. 


Artery. 

Paulus  ^Egineta,  4. 

femoral  artery  first  tied  at  Pou- 
part's  ligament  by  Severinus,  8. 

contraction  of  arteries,  important 
in  arresting  hemorrhage,  10. 

means  of  arresting  hemorrhage  in 
subcutaneous  divisions,  11;  in 
ordinary'  accidents,  11;  in  ves- 
sels partially  divided,  12;  in 
artery  surrounded  by  tight 
ligature,  12. 

strengtii  depends  on  its  external 
coat,  12. 

agencj'  of  walls  of  the  vessel  in  pro- 
cess of  repair,  12. 

coagulum  forms  in  wounds  of 
arteries,  3. 

longitudinal  slit  maj'  heal  without 
obliteration  of  canal,  14. 

brachial  artery  of  a  stump,  22. 

narrowing  of  arteries  in  stump,  32. 

minute  anatomy  of  the  ai'teries,  45. 

time  required  for  complete  cica- 
trization,  97. 

appearances  noticed  in  vessel  of 
amputated  stump,  100,  149. 

pei'manence  of  the  umbilical  ar- 
tery. 129. 

Baumgarten  maintains  that  an 
artery  can  be  tied  without  for- 
mation of  thrombus,  141. 

aorta,  112,  126,  127. 

axillarv,  100. 

brachial,  22,  98. 

carotid,  50,  51.  52,  53,  70,  71,  76,  78, 
79,  83,  85,  91. 

cerebral,  26. 

ductus  arteriosus,  32,  111,  113. 

femoral,  8,  48,  49,  53,  55,  57,  58,  59, 
62,  65,  67,  88,  99,  104. 

hypogastric  (umbilical).  111,  113, 
129,  131,  132,  133. 

iliac,  89,  96. 

subclavian,  86,  95. 

tibial,  99,  100,  102,  103,  104,  106. 

umbilical,  see  hypogastric. 
Asepsis. 

absence  of  thrombus  with  complete 
asepsis,  43,  44. 
Avenzohar. 

duties  of  physicians,  5. 

use  of  ligatures,  5. 
Averrhoes. 

use  of  ligatures,  5. 
Avicenna. 

duties  of  physicians,  5. 

confines  ligatures  to  arteries,  5. 
Bandages  applied  about  limb  and  pro- 
visional  ligatures  before  am- 
putation, 3. 
Barwell. 

ox-aorta  ligature,  39. 


Baumgarten. 

observations  on  the  growth  of  the 
thrombus,  23. 

growth  of  granulations,  23. 

behavior  of  the  endothelial  cells,  24. 

agreement  with  Pfitzer,  29. 

I'eply  to  Senftlel^en,  29. 

appfication  of  double  ligature,  42. 

absence  of  tiirombosis  witli  strict 
asepsis,  43,  44. 

summary  of  views  on  formation  of 
thrombus,  43. 

Virchow's  axiom    confirmed,  44. 

umbilical  artery  in  the  adult,  113. 

the  ductus  arteriosus  an  example 
of  the  "  t.ypical  process  of  in- 
complete obliteration,"  113. 

permanence  of  the  umbilical  arterj', 
129. 

his  view  disproved,  135. 

maintains  that  an  arteiy  can  be 
tied  without  formation  of 
thrombus,  141. 

the  extent  of  traumatism  the  most 
impoi'tant  factor  in  the  pro- 
duction of  the  thrombus,  141. 
Beale. 

arteries  of  horses  and  donkeys,  28. 

opening  in  elastic  coat  filled  with 
colorless  substance,  28. 

agency  of  white  corpuscles,  28. 
Bell. 

pressure  exerted    by   surrounding 
tissue    prevents    hemorrhage, 
adliesive  inflammation  subse- 
quently uniting  the  walls,  10. 
Bertaplagia. 

transfixion  of  vessel,  6. 
Billroth. 

adopts  views  of  Bul)noff,  20.       [20. 

proliferation  in  white  corpuscles, 
Blandin. 

pronounces  in  favor  of  the  organiz- 
ing- power  of  the  thrombus,  13. 
Bleeding — see  hemorrhage. 
Blood. 

action  of  blood  in  coagulating  in 
arteries,  42. 

red  corpuscles  absorbed,  10. 

wall  of  the  vessel,  an  important 
factor  in  preserving  the  fluidity 
of  tlie  blood,  44. 

action  of  blood  between  two  liga- 
tures, 12. 

plaques  seen  in  dogs,  141. 
Botalli. 

ductus  Botalli,  15,  32. 
Bouchon. 

Petit,  9, 

brachial,  9. 
Bouillaud. 

pronounces  in  favor  of  organizing 
power  of  the  thrombus,  12. 


Index. 


173 


Briicke. 

wall  of  the  vessel,  an  important 

factor  in  preserving-  the  lluidity 

of  the  blood,  44. 
Bruno. 

method  of  passing  the  ligature,  6. 
cause  of  failure  of  the  ligature,  41. 
formation  of  new  tissue  in  place  of 

the  catgut,  41. 
Biyant. 

effect  of  torsion,  35. 

denies    that    ligatured    portion  of 

vessel  sloug-hs,  37. 
ampulla-like  shape    of  thrombus, 

139. 
Bubnoff. 

passage  of  white  corpuscles,  20. 

wandering"  cells,  30,  31. 

results  with  vermilion    granules, 

20. 
Callender. 

action  of  the  blood  in  coagulation, 

33. 
Callus. 

description  of  external    callus  by 

Lidell,  95. 
formation  of  callus,  56,  63,  77,  79, 

80,  88,  138,  143,  144. 
absorption  of  outer  walls  by  the 

granulation  tissues  of  the  cal- 
lus, 76. 
retrograde  change   in  tiiird  stage 

of  repair,  146. 
Canalization  of  thrombus,  15,  18,  23, 

of  librine  (Zahn),  39. 
Canalized  fibi'ine,  29. 
Capillaries. 

formation,  63. 

communicating  with  lumen,  145. 
Cauter}'. 

Hotel  Dieu. 
Eomans,  2. 
Greeks,  5. 
Arabians,  5. 
Moors. 
Rhazes,  5. 
Albucasis,  5. 
Guillemeau,  8. 
Wiseman,  8. 
Tagaliacozzi,  8. 
Cells. 

all  tissues  developed  from  primary 

cells,  14. 
origin  of  new  cell-growth,  26. 
cells  of  the  lining  membrane,  19. 
formation  of  cells  in  first  stage  of 

repair,  142. 
cell    growth    not    supplied    from 

intima  alone,  143. 
origin  of  cells  in  inflamed  tissues, 

20. 
Celsus. 

his  knowledge  of  the  ligature,  3. 


Celsus. 

means  used  to  arrest  hemoi'rhage 
by  the  Romans,  2. 

amputation    avoided   by   his    suc- 
cessors, 3. 
Chelius. 

denies  the  pai'ticipation  of  the  in- 
ternal coag'ulum,  13. 
Cicatricial  tissue. 

formed  bv  walls  of  vessel  with  the 
clot,  13. 

in  femoral  at  two  ends  of  vessel 
after  amputation,  95. 

examples  of  complete  cicatrization 
in  external  iliac  and  common 
carotid,  95. 
Cicatrix. 

organization  of  the  cicatrix,  54,  67. 

permanent  cicatrix,  69. 

the  completed  cicatrix,  72,  80,  88, 
90,  93,  94. 

microscopical  study,  73,  74,  75,  88. 

time  required,  for  completion  of 
process  of  cicatrization,  97. 

nature's  method  of  forming  a  cica- 
trix, 111. 

nature  of  cicatrix,  139,  147,  148. 

shape  of  cicatrix,  39,  74,  148. 

cicatrix  of  an  artery  compared  to 
the  cicatrix  marking  openings 
of  the  ductus  arteriosus,  149. 

cicatrization  after  amputation,  150. 

nature  of  cicatrix  in  aortic  walls, 

Circulation  discovered  by  Harvey,  8. 
Coagulation . 

Jones,  11. 

Callender,  23. 

Chelius,  13. 

Lister,  23. 

Conheim,  42. 

Baumgarten,  141. 

Osier,  "44. 

action  of  blood  in  coagulating  in 
arteries,  23,  43. 

Inflammatory  changes  in  tlie  endo- 
thelium cause  coagulation  of 
the  blood,  44. 

coagulation  of  the  blood  due  to  in- 
juries of  the  intima,  44. 
Coagulum. 

contributes  to  suppression  of  hem- 
orrhage, 11. 

decolorization  of  clot,  13. 

acting  as  a  foreign  body,  12. 

formed  in  wound  of  arteries,  13. 

pai'ticipation  of  the  internal  coagu- 
lum, 13. 

mixed  clot,  43. 

clot  most  adherent  when  rupture 
in  the  elastic  lamina  has  oc- 
curred, 49. 

transparence  of  the  clot,  54. 


174 


The  Ligature  of  Arteries. 


Cohn. 

white  corpuscles  as  organizing'  ele- 
ments, 19. 
Compensatory  endarteritis,  105. 
Compression. 

Petit  proposes  compression  in  place 
of  the  ligature,  9. 
Conheim. 

rediscoverj'-    of  passage  of    white 
corpuscles,  19.  [20. 

origin  of  cells  in  inflamed  tissues, 
action  of  blood  in  coagulating  in 
arteries,  42. 
Connective  tissue,  13. 
Contraction. 
Morand,  9. 

contraction  of  arteries  as  nature's 
means     of     arresting    hemor- 
rhage, 10. 
Verneuii,  33. 
Thorn  a,  32. 
Author,  54. 

contraction   seen  in  umbilical  ves- 
sels, 10. 
Jones,  11. 

contraction  of  walls,  54. 
Cooke. 

describes  Pares  method  of  "stitch- 
ing" the  vessels,  8. 
Coopei". 

used  animal  ligatures,  39. 
Cord. 

conversion   of  long  trunk  into    a 

cord,  72,  102,  104. 
variation  in  lengtli,  149. 
Cornil. 

arteritis,  22. 

vegetation  of  inner  tunic  in  chronic 
endarteritis,  26. 
Corpuscles. 

white,  13,  16,  17,  18,  20,  28,  29. 

red,  10. 

earlv  notice  of  the  white  corpviscles, 

'13. 
cells  the  product  of  the  white  cor- 
puscles   and     the    wandering 
cells,23.  [29. 

agency  of  white  corpuscles,  17,  28, 
proliferation  in  white    corpuscles, 

20,  47. 
passage  of  white  corpuscles,  20. 
white  corpuscles  as  organizing  ele- 
ments, 19. 
rediscovei-y  of  passage  of  white  cor- 
puscles, 19. 
Scliultz  considers  that  the  process 
of  repair  is  completed  by  white 
corpuscles,  29. 
Costello. 

paper  on  torsion,  35. 
Couvercle. 

Petit,  9,  98. 
brachial,  98. 


Decolorization  of  clot,  12. 
Dent. 

tendon  ligature,  40. 
Deschamps. 

union  by  first  intention,  21. 
Dionis. 

advantages  of  tlie  ligature,  9. 
Dog. 

aneurism  in  dogs  and  horses,  13, 
14. 

woimd  of  arteries  and  repair,  13. 

experiments  on  dogs,  47,  48. 

appearance  of  thrombus  in  dogs, 
140. 
Ductus  arteriosus. 

obliteration  of  ductus  arteriosus, 
111. 

nature  of  the  histological  elements, 
111. 

Thoma's  description  of  the  anato- 
my and  changes  in  the  ductus 
arteriosus,  111. 

intima.  111,  112. 

muscular  cells.  111. 

elastic  lamina.  111,  112. 

endothelium,  111,  112. 

media,  112. 

muscular  cells,  112. 

narrowing  of  the  lumen,  112. 

muscular  elastic  layer  of  intima, 
112. 

hj'aline  connective  tissue,  112. 

resemblance  of  muscular  tissue  and 
the  connective  tissue  of  the  in- 
tima of  the  aorta,  112. 

an  example  of  tlie  "  typical  process 
of  incomplete  obliteration " 
113. 

investigations  of  the  foetal  vessels, 
114. 

anatomical  structvu-e,  124. 

hyaline  degeneration,  125. 

strengthenuig  of  outer  wall,  125. 

ciirular  muscular  fibres,  126. 

obliteration  of  aortic  opening',  126. 

intima  thickened,  126. 

hyaline  tissue,  126.  [126. 

cells  going-  from  intima  and  media, 

cell  proliferation,  126. 

muscular  cells,  126. 

formation  of  thrombus,  in  case  of 
forty-two  daj's,  unusual,  126. 

development  of  ligamentum  ar- 
teriosum,  126.  [127, 

nature   of  cicatrix  in  aortic  wall, 
DudukalofT. 

action  of  granulation  tissue,  25. 
Durante. 

inflammatory  changes  in  the  endo- 
thelium cause  coagulation  of 
the  blood,  44. 

experiments,  23. 

necrosis  of  walls,  23. 


Index. 


175 


Duration  of  process  of  obliteration  lon- 
ger than  usually  ascribed  to  it,  138. 
for    larger    vessels    three    to    six 
months,  183. 
Ebel. 

denies  the   participation  of  the  in- 
ternal coagulation,  13. 
Egyptians  do  not  mention  use  of  liga- 
ture, 1. 
Endarteritis,  24,  28, 
idiopathic,  26. 
compensatory,  105. 
obliterating,  102,  104,  105,  108. 
case  of  endarteritis  obliterans  tibite, 

109. 
summary  of  results  from  a  case, 109. 
not  originating  in  inflammation  of 

the  coats  of  the  vessels,  137. 
vegetation  of  inner  tunic,in  chronic 
endarteritis,  26. 
Endothelium,  19.  24,  26,  28. 

behavior  of   the  endothelial  cells. 

24, 
the  origin  of   white  blood  corpus- 
cles, 31. 
action  of  endothelium,  47,  55,  59. 
growth  of  endothelium,  61,  64,  67. 
in  ductus  arteriosus,  111,  112. 
inflammatory  changes  in  the  endo- 
thelium cause  coagulation  of 
the  blood,  44. 
new  formation  from  the  endothe- 
lium and  subjacent  elements  of 
the  intima,  31. 
action  of  endothelium  in  producing 
connective  tissue,  19. 
Experiments. 

dog,  single  ligature,   femoral,  two 
days,  48. 
si ngle    ligature,     femoral, 

eighty  houi's,  49. 
single  ligature,  carotid,  four 

days,  50. 
single  ligature,  one  week,  51. 
single  ligature,  one  week,  52. 
single  ligature,  carotid,  femo- 
ral, nine  days,  53. 
single  ligature,  femoral,  ten 

daj's,  55. 
double  ligature,  femoral,  one 

week,  57. 
double  ligature,  femoral,  one 

week,  58. 
double   ligature,    femoral, 

fourteen  daj^s,  59. 
double  ligature,  femoral,  one 

month,  62. 
double  ligature,  femoral,  one 

month,  65. 
double  ligature,  femoral,  three 

months,  67. 
temporaiy    ligature,    carotid, 
three  months,  70. 


Experiments. 

dog,  temporary  ligature,    carotid, 
one  week,  70. 
temporary  ligature,    carotid, 
four  months,  71. 
horse,  carotid,  two  weeks,  76. 
carotid,  one  month,  76. 
carotid,  two  months,  78. 
carotid,  four  months,  79. 
man,  ligatures  in  continuity,  82. 

common  carotid,  four  daj's, 

83. 
common     carotid,     fourteen 

days,  85. 
subclavian, forty-six  days,  86. 
femoral,  fifty-five  days,  88. 
external  iliac,   one    hundred 
and  thirty  days,  89.        [91. 
common  carotid,  four  years, 
amputation,  lacerated  brachial, two 
hours,  98. 
femoral, twenty  hours, 

99. 
tibial,  one  week,  99. 
tibial,  100. 
axillary,     one    week, 

100. 
tibial,     three    weeks, 

102. 
tibial,  three  weeks, 

103. 
posterior  tibial,  three 

weeks,  104. 
femoral,  fifteen  vears, 
104. 
endarteritis  obliterans  tibia?,  seven- 
teen days,  106. 
foetal  vessels,  ductus  arteriosus,  at 
term,  114. 
ductus  arteriosus,  a 
few    days    after 
birth,  115. 
ductus  arteriosus, 
twenty-eight  days, 
116. 
ligamentum  arterio- 
sum  thirty -five 
days,  117. 
ligamentum  arterio- 
sum,  forty- two 
days,  118. 
ligamentum  arterio- 
sum,    eighteen 
months,  119. 
ligamentum  arterio- 
sum,     five    years, 
120. 
ligamentum  arterio- 
sum,    thirty-eight 
years, 
ligamentum  arterio- 
sum,    fort  y-t  w  o 
years,  122. 


iy6 


The  Ligature  of  Arteries. 


Experiments, 

foetal  vessels,  ligamentuni  arterio- 
sum,     forty-seven 
years,  123. 
hypogastric  arter^'-,  a 

few  days,  129. 
hypogastric    artery, 
thirty -six    days, 
131. 
I'emains   of    the  ar- 
tery, adult,  132. 
hypogastric    artery, 
in  monkey,  133. 
summary  of  experiments, 
dog,  72. 
horse,  80. 
man,  93. 

amputations,  107. 
ductus  arteriosus,  124. 
hypogastric  arter^',  134. 
general  summary,  138. 
Fallopio. 

described  operation  of  ligature,  8. 
Fermeture,  35. 
Ferri. 

uses  sickle-shaped  needle  for  liga- 
tures, 6 
Fibrine. 

development  of  fibrine,  14. 
aneurismal  sac  formed  from  layer 

of  libiine,  29. 
coagulated    fil^rine    changed    into 

connective  tissue,  14. 
formed    by    union    of     fibrinogen 
and  pai-aglobulin,  42. 
Fibi'ine  ferment,  42. 
Fibrinogen,  42. 
Fii'st  intention. 

healing  by  first  intention,  10,  53, 

55',  138,  143. 
Deschamps.  21. 
Tait,  21. 
First  stage  of  repair,  93,  139. 

growth  of  tissue  on  inner  walls  of 

the  vessels,  108. 
spindle-shaped  cells  with  elongated 

nuclei,  108. 
growth  from  both  coats  of  vessel, 

108. 
obliterating    endarteritis    in    ear- 
liest stage,  108. 
inversion  of  coats,  108. 
walls    infiltrated  with    wandering 

cells,  109. 
attachment  of  thi'ombus  to  walls, 

109. 
narrowing  of  lumen,  109. 
Foerster. 

organization  of  the  tlirombus,  19. 
Foetal  vessels. 

umbilical  vessels  and  ductus  Botalli 

15 
closure  of  foetal  vessels,  111. 


Foetal  vessels, 

ductus  arteriosus,  111. 

experiments  on  the  ductus  arteino- 
sus,  114. 

ligamentum  arteriosum,  117. 

summary  of  experiments  on  ductus 
arteriosus,  124. 

experiments  on  hypogasti'ic  artery, 
128. 

summary  of  experiments  on  hypo- 
gastric artery,  134. 
Forceps. 

sliding  forceps  from  Pompeii  in 
Naples  Museum,  4. 

HouUier,  7. 

Par6,  7,  9. 

new  forceps  invented  by  Guille- 
meaii,  7,  8. 

"  Valet  a  Patin,"  9. 

modification  of  the    forceps.  Van 
Soligen,  8. 
Frencli  surgeons. 

use  of  torsion,  35. 
Fricdlander. 

origin  of  new  cell-growth,  26. 
Froissement,  35. 
Galenus  makes  mention  of  ligature,  3. 

advises  use  of  styptics  and  liga- 
tures, 3. 

thinks  vessels  are  healed  bj^  growth 
from  the  surrounding  tissues, 4. 

mouth  of  the  vessel  closed  by  gran- 
ulations, 7, 
Gendrin. 

pronounces  in  favor  of  the  organiz- 
ing power  of  the  thrombus,  12. 

action  of  blood  between  two  liga- 
tures, 12. 
German  writers,  13. 
Gooch. 

coalescence  of  vessels  and  gi'owth 
of  tissue,  10, 
Granular  bodies,  14,  17,  23,  29. 

granulation  cells  beginning  to  in- 
vade tlie  lumen  at  end  of    a 
week,  108. 
Granulations. 

observations  by  Baumgarten,  23. 

mouth  of  vessel  closed  by  granula- 
tions, 7. 
Granulation  tissue. 

action  of  granulation  tissue,  25. 

appearance  of  granulation  tissue, 
51,  53,  54,  56,  58,  59,  63,  64,  66, 
70. 

absorption  of  the  outer  walls  by 
the  granulation  tissues  of  the 
callus,  76. 

penetrating  inner  coat,  85. 

formed  in  axillary  after  one  week, 
100. 

tibial  after  three  weeks,  102. 

formation  outside  the  vessel,  143. 


Index. 


177 


Gi'anulation. 

a  well-marked  structure  in  healing 

by  first  intention,  143. 
formation  of  callus,  143. 
invasion  of  the  interior  of  the  ves- 
sel, 144,  145. 
Granuligera. 

occurring   in   silk  or  hempen  liga- 
tures, 40. 
Greeks. 

use  of  ligature  by  Greek  writers,  4. 
Greifenbei'ger. 

ligature  not  mentioned  by  Hippo- 
crates, 1. 
Greenfield. 

changes  in  coats  of  the  arteries,  38. 
spindle-shaped  ceils  seen,  28. 
Guillemeau. 

confined  the  use  of  ligature  to  pri- 
mary amputations,  8. 
Guthrie. 

experiments  on  animals,  13. 
longitudinal  slit  may  heal  without 
obliteration  of  the  canal,  13. 
Guy  de  Chauliac. 

method  of  applying  the  ligature,  6. 
Haeser. 

ligature  not  mentioned  by  Hippo- 
crates, 1. 
quotation  fi-om  Paulus  ^gineta,  3. 
Harvey. 

discovery  of  the  circulation,  8. 
Heliodorus. 

familiar  witli  torsion,  3. 
describes  method  of  performing  it, 
Hematoidin  crystals,  26.  [3. 

Hemorrhage. 

means  used  to  arrest,  time  of  C'el- 

sus,  2. 
lint  and  vinegar  used  to  arrest,  2. 
use  of  escharotics,  2. 
bandages  applied  about  limb  before 

amputation,  3. 
secondary  hemorrhage  caused  by 
including   surrounding  tissues 
with  ligature,  10. 
nature's  method  of  arresting  hem- 
orrhage, 10,  11,  12. 
coagulum   contributes   to  its   sup- 
pression, 11. 
arrested  without  aid  in  considerable 

arteries,  14. 
thrombus  the  most  important  fac- 
tor in  the  suppi'ession  of  hem- 
orrhage, 21.  [36. 
safety  from  hemorrhage  in  torsion, 
dense     outer    "wall    a    protection 

against  hemorrhage,  49. 
arrested    by  coag'ulation  of  blood 
without  and  thrombus  within 
vessel,  107. 
condition  preliminary  to  secondaiy 
hemorrhage,  104. 


Henle. 

coagulated    fibrine    changed    into 

connective  tissue,  14. 
repeats  experiments  of  Jones  and 

Stilling,  14. 
first  elaborate  microscopical  study 

of  the  question,  14. 
reorg'anization  of  the  blood  in  sub- 
stance, 14. 
granular  bodies,  14. 
Heubner. 

cells  in  syphilitic  arteries,  24.  a 
endothelium  the  most    important 

factor,  24. 
cerebral  artery  in  syphilis,  26. 
Hewson. 

experiments  with  acupressure,  37. 
Hildanus. 

favors  the  use  of  the  licature,  8. 
Hippocrates  regarded  by  some  writers 
as  the  discovei-er  of  the  ligature,  1. 
His. 

cells  of  the  lining  membrane,  19. 
endothelium,  19. 
Holmes. 

objects  to  the  opening  of  the  sheath 

with  tlie  knife,  34. 
use  of  metallic  ligatures,  42. 
Holt. 

use  of  wire  ligatures,  42. 
Horse. 

aneurisms   in  dogs  and   horses,  13, 

14. 
experiments  on  horses,  47,  75. 
Beale  on  the  arteries  of  horses  and 
donkeys,  28. 
Houllier. 

used  hook  and  forceps,  7. 
Hunter. 

healing  by  first  intention,  10. 
organization   of  the  thrombus,  10, 

47. 
agency  of  the  vessel  walls,  10. 
effects     of    rupturing  an     artery, 

10. 
degeneration  of  arteries,  10. 
internal    coagulum  contributes  to 
the  suppression  of  hemorrhage, 
11. 
Hyaline  degeneration. 

ductus  arteriosus,  125. 
hypogastric  artery,  131,  135. 
ligamentum  arteriosum,  117. 
Hypogasti'ic  artery. 

see  vimbilical  artery. 
Intima. 

vascularized  through  the  media,  19. 
growth  of  cells  of  the  intima,  28. 
intima  in  ductus  arteriosus,lll,  112. 
muscular  elastic  lamina  of  intima 
in  ductus  artei'iosus,  112. 
Inversion. 

inversion  of  inner  walls,  9,  108. 


178 


The  Ligature  of  Arteries. 


Italians. 

state  of  medicine,  6. 
Italian  writers,  13. 
Jamieson. 

used  animal  ligatures,  39. 
Jones. 

experiments  on  the  closure  of  ves- 
sels, 11. 
experiments  on  horses,  11. 
nature's  means  of  arresting  hemor- 
rhage, 11. 
artery  divided  subcutaneously,  11. 
suppression  of   hemorrhage  in  or- 
dinary accidents,  12. 
in  an  artery  partially  divided,  12. 
anevirism    in  dogs  and   horses,  12. 
action  of  tight  ligature,  12. 
strength  of  an  artery  depending  on 

its  external  coat,  12. 
the     first     to     bring     to     promi- 
nence the  agency  of  the  walls 
of  the  vessel  in  the  process  of 
repair,  12. 
repair     bi'inging     in     organizable 
lymph    from    the  vasa    vaso- 
rum,  13. 
Kirkland. 

contraction  of  arteries  important 
in  arresting  hemorrhage,  10. 
Koch. 

failure  to  use  ligatures  in  amputa- 
tions, 35. 
Kocher. 

oi'ganization  of  the  thrombus,  21. 
changes  found  in  acupressure,  21. 
action  of  the  endothelium,  21. 
comparison  of  the  ligature  and  tor- 
sion, 36. 
opinion  that  acupressure  will  super- 
sede the  ligature,  36. 
study  of  acupressure  and   acutor- 

sion,  37,  38. 
adaptation  to  diseased  arteries,  39. 
Lamina  elastica. 

ruptures  of  lamina  elastica,  67. 
Lancereaux. 

fate  of  the  embolus,  19. 
Lanfranchi. 

method  of  arresting  hemorrhage,  6. 
Lee. 

concludes  that  the  clot  acts  as  a 

foreign  body,  12. 
arteries  of  horses  and  donkey,  28. 
opening  in  elastic  coat  filled  with 

colorless  substance,  28. 
agency  of  white  corpuscles,  28. 
Leucocytes,  102. 
Levator  muscle,  69. 
Lidell. 

description  of  the  external  callus,  95 
Lig  amentum  arteriosum. 
development,  126. 
experiments  on,  117. 


Ligature,  Lisfranc  on  history  of,  1. 
first  recorded  use  of,  1. 
Hippocrates  believed  by  some  to  be 

the  inventor,  1. 
Alexandrian  school,  2. 
Celsus   on    means  used    to  arrest 

hemorrhage    among    the    Eo- 

mans,  2. 
provisional  ligatures  used  by  Ar- 

chigenes,  3. 
Claudius  Galenus  makes  mention 

of  ligature,  3. 
use  advised  by  Galenus,  3." 
obtained  by  him  on  the  Via  Sacra, 

4. 
advised  by  Antyllus,  4. 
Aetius,  4. 

Pavilus  J5gineta,'4. 
Rhazes,  5. 
Albucasis,  5. 
Averroes,  6. 
not  confined  to  small  vessels  before 

the  time  of  Pare,  4. 
Chauliac,  6. 
method  of  applying  described  by 

Bruno,  6. 
confined  to  large  vessels  in  middle 

ages,  6. 
Tagault,  7. 
Par6,  7,  34. 
Guillemeau,  8. 
Fallopio,  8. 
mediate    ligature     inti'oduced    by 

Italian  school,  6. 
pi'ovisional  ligatures  before  ampu- 
tation, 3. 
Petit  proposes  compression  in  place 

of  the  ligature,  9. 
Sharp,  9. 
Monro,  9. 

ligature  en  masse  Dionis,  9. 
Petit,  9. 
Morand,  9. 
Pouteau,  9. 

action  of  ligature  applied  subcuta- 
neously, 11.  [12. 
tight  ligature  surrounding  artery, 
reparative  process  independent  of 

the  ligature,  14. 
application  of  double  ligature,  42. 
Jones  brought  about  the  use  of  the 

single  thread  ligatvire,  39. 
cutting  both   ends  short  adopted, 

39. 
Lister  s  method  of  preparing  cat- 
gut ligatures,  41. 
dangers  attending  silk  or  hempen 

ligatvires,  40. 
organization  of  the  ligature,  41. 
mode  of  action  of  a  strong  ligature, 

139. 
mode  of  action  of  lightly  applied 

ligature. 


Index. 


179 


Ligature. 

experiments  with  double  ligatxu*es, 

143. 
function  of  the  ligature,  144. 
occlusion  of  artery  without  danger 
of  secondary  hemorrhage,  151. 
Abernethy  sanctions  use  of  double 

ligature,  35. 
ligature  one  of  the  fix-st  obstacles  to 
healing  by  the  first   intention, 
37. 
double,  29,  34,  35,  43,  57,  58,  59,  63, 

64,  143. 
modified,  36. 
silk,  3,  6,  40. 
linen,  2,  4. 
hempen,  40. 
cotton,  53,  59. 
animal,  4,  37,  39. 

catgut,  4,  39,  40. 

catgut,  cai'bolized,  40,  41. 

buckskin,  39. 

chamois,  39. 

carbolized  nei've,  33,  34. 

chroniicized,  52. 

ox  aorta,  39. 

kangaroo,  39. 

whalebone  tendon    (Ishig- 

uro),  39. 
hair,  39. 
metallic,  37,  43. 
Linen  thread  used  as  ligature,  3. 
Lint  used  to  arrest  hemorrhage,  3. 
Lisfranc,  history  of  the  ligature,  1. 
Lister. 

action  of  the  blood  in  coagulation, 

33. 
dangers  attending  silk  or  hempen 
ligatures,  40. 
Longitudinal  slit  in  artery  may  heal 
withovit    obliteration     of     the 
canal,  13. 
Lung. 

experiments  with  pieces  of  lung,  29. 
Lymph. 

becomes  organized,  13. 
lymph  spaces,  45. 
Massachusetts    General  Hospital,  Bos- 
ton.    Specimens  from, 
lacerated  brachial,  98. 
femoral,  99. 
tibial,  101. 

endarteritis  obliterans  tibiae,  106. 
Maunder. 

formation  of  the  blood  clot,  23. 
sanctions  use  of  double  ligature,  35. 
Maxwell. 

cutting  the  ends  of  ligatures  short, 
39. 
Mayer. 

cells  the  product  of  the  white  cor- 
puscles and  the  wandering 
cells,  33. 


Meckel. 

among  the  fii'st  to  call  attention  to 
the  white  corpuscle,  13. 
Media. 

proliferation  of  cells  of,  into  the 

intima,  19. 
infiltration  and  absorption  of  the 

ends  of  the  media,  55. 
division  of  media,  99,  103,  104. 
media  in  ductus  arteriosus,  113. 
Methods,  153. 

Mliller's  fluid,  153. 
alcohol,  153. 
preservative  fluids,  153. 
sections,  153. 

Hartnack  microscope,  154. 
aseptic  precautions,  154. 
Micrococcus. 

occurring  in  silk  or  hempen  liga- 
tures, 40. 
Microscope. 

first  elaborate  microscopical  study 
of  the  question,  14. 
Middle  ag'es. 

revival  of  study  of  anatomy,  6. 
ligature  confined  to  large  vessels,  6. 
Middle  coat  participating  in  the  obliter- 
ating process,  107. 
Monro. 

advantag'es  of  the  direct  ligature,  9. 
Morand. 

confirms  views  upon  the  formation 
of  the  thrombus,  9. 
Morel. 

invention  of  the  tourniquet,  8. 
Muscular  cells,  69,  70,  73,  74,  107,  126. 
a  prominent  and  essential  feature 

of  the  arterial  cicatrix,  138. 
the  character  of  muscular  cells,  147. 
comparison  with  muscular  cells  of 

vessel  walls,  148. 
development  in  walls  of  uterus,  148. 
muscular  cells  in  ductus  arterio- 
sus, 112. 
Museums. 

Army  Medical  Museum,  86,  88,  89. 
Warren  Museum,  83,  85,  91. 
Naples. 

sliding  forceps  in  the  Naples  Mu- 
seum, 4. 
Narrowing  of  arteries  in  stump,  82,  89. 
Natui'e. 

nature's  means  of  arresting  hemor- 
rhage, 11, 107,  109. 
nature's  effort  to  prevent  secondary 
hemorrhage,  104. 
Neci'osis  of  walls,  33. 
Nephritis. 

condition  of  arteries,  33. 
Notta. 

maintains  that  blood  clot  was  cap- 
able only  of  retrograde  change, 
17. 


i8o 


TJie  Ligature  of  Arteries, 


Ogston. 

method  of  closure  of  the  vessel,  37. 
comparative    strength  of   arteries 
secured  by   ligature,   acupres- 
sure and  torsion,  38. 
blood  pressure  in  the  human  sub- 
ject, 38. 
experiments  of  Ogston,  139. 
Omnis  cellula  e  cellula,  16. 
Opening  of  the  vessel,  56,  66,  80,  84. 
axillaiy  at  end  of  a  week,  108. 
at  end  of  the  first  month,  145. 
Organization  of  the  thrombus,  10,  12, 

14,  16,  17,  19,  21,  25,  47. 
Oribasius. 

torsion  used  in  his  time,  5. 
Osier. 

lectures     on    coagulation    of    the 
blood,  44. 
Par6. 

use  of  ligature,  7. 

makes  its  vise  universally  applica- 
ble, 7. 
method  of  application,  7. 
mouth  of  the  vessel  closed  by  gran- 
ulations, 7. 
plate  of  the  forceps,  9. 
Paulus  ^gineta. 

ligature  of  vessels  after  amputa- 
tion, 8. 
mentions  use  of  ligature,  4. 
Petit. 

investigations    on  the  healing  of 

arteries,  9. 
proposes  compression  as  substitute 

for  ligature,  9. 
agencj"^  of  the  thrombus  in  check- 
ing hemorrhage,  9. 
efficiency  of   the  inner  coagulum, 
21. 
Pfltzer. 

wounds  are  filled  with  white  throm- 
bus, 29. 
growth  of  endothelium  takes  place, 
and  granulation  tissue  outside 
the  vessel,  29. 
Physick. 

suggests  use  of  animal  ligature,  39. 
Plastic  clot  in  axillary  after  one  week, 

100. 
Plates. 

description  of  plates,  158. 
Pollock. 

use  of  metallic  ligature,  42. 
Pompeii. 

sliding  forceps  from  Pompeii  at  the 
Naples  Museum,  4. 
Pouteau. 

denies  the  presence  of  a  coagulum, 

9. 
swelling  of    surrounding    cellular 
tissue  the  chief  obstruction  to 
hemorrhag-e,  9. 


Porta. 

collateral  circulation  and  material 
of  ligatures,  15. 
Portal  vessels. 

obliteration  of  the  portal   vessels 
takes  place  without  the  inter- 
vention of  thrombus,  15. 
Pi'axagoras. 

the  difference  between  arteries  and 
veins,  1. 
Pressure. 

pressure    exerted  by  surrounding 
tissue    prevents    hemorrhage, 
adhesive  inflammation,  subse- 
quently uniting  the  walls,  10. 
more  reliance  to  be  placed  on  pres- 
sure, 14. 
blood  pressure  in  the  human  sub- 
ject, 38. 
pressure  sufficient  to  prevent  bleed- 
ing, 35. 
Proliferation. 

of  endothelium,  20. 
Raab. 

cicatrix  following  ligature,  24. 
experiments  on  arteries  and  veins, 

24. 
ramification  of  spindle-cells,  25. 
union  by  first  intention,  25. 
organization  of  the  thrombus,  25. 
denies  the  participation  of  white 
corpuscles,  25. 
Ran  vie  r. 

arteritis,  22. 
Recklinghausen. 

investigations,  19. 
Regeneration  of  arteries,  10. 
Reinhardt. 

theories,  16. 

organization  of  the  thrombus,  17. 
granular  cells,  17. 
Renversement,  35. 

Reorganization  of  the  blood    in    sub- 
stance, 14. 
Retraction. 

Petit  and  others,  9. 
in  brachial  arteiy,  98,  107. 
Celsus,  2. 
Morand,  9. 
Pouteau,  9. 
Jones,  11. 

in  subclavian  artery,  87. 
retraction  within  sheath,  107. 
author's  observations,  56,  77,  80. 
Retrograde  metamorphosis,  13. 
Rhazes.  [5. 

use  of  ligature,  styptic  and  cautery, 
Ribes. 

pronounces  in  favor  of  organizing 
power  of  the  thrombus,  12. 
Rindfleisch. 

first  changes  occur  in  white  cor- 
puscles, 18. 


Index. 


i8i 


Roche. 

pronounces  in  favoi*  of  the  org'aniz- 
ing-  power  of  the  thrombus,  13. 
Roger  of  Parma. 

introduction  of  mediate  Hgature,  6. 
Rokitansky. 

gives  prominence  to  the  action  of 

the  vessel  walls,  15. 
obliteration  of  the  portal  vessels 
takes  place  withovit  the  inter- 
vention of  thrombus,  15. 
umbilical  arteries  and  Ductus  Bo- 

talli,  15. 
diversion  of  curi-ent  into  collateral 
channels,  15.  [15. 

vascularization  of  the  thrombus, 
organization  of  the  thrombus,  17. 
Romans. 

means  vised  for  arresting   hemor- 
rhage among,  2. 
'*  Royal  styptic,"  8. 
Rixfus  of  Ephesus. 

recognized  difference  between  ar- 
teries and  veins,  3. 
familiar  with  torsion,  3. 
Ruptures. 

rupture  of  inner  walls,  9. 
ruptures  in  the  arteries,  32. 
Rust. 

denies  the  participation  of  the  in- 
tei-nal  coagulum,  13. 
Sanson. 

pronounces  in  favor  of  the  organiz- 
ing power  of  the  thi-ombus,  12. 
Santo. 

process  similar  to  acupressure,  6. 
Saviard. 

invention  of  the  aneurism  needle,  8. 
Savoi-y. 

advises  opening  the  sheath  with  the 
knife,  34. 
Scabbing,  healing  by,  79. 
Scarpa. 

maintains  the  adhesion  of  the  walls, 
without  the  intervention  of  the 
clot,  13. 
Schultz. 

process    of    repair    completed    by 

white  corpuscles,  29. 
shape  of  the  cicatrix,  29. 
remarks  oa-dissection  of  vessel,  34. 
shape  of  the  cicatricial  tissue,  74. 
Schwann. 

"cell  theory,"  14. 
Secondary     hemorrhage    (see    hemor- 
rhage), 
caused  by  including   surrounding 

tissues  with  vessel,  10. 
condition  pertaining  to  secondary 
hemorrhage,  104. 
Second  period  in  the  process  of  repair, 
66,  85,  87,  95,  139,  145. 
external  and  internal  callus,  139. 


Senftleben. 

reply  to  Baumgarten,  29. 

expei'iments  vdth  the  double  liga- 
ture, 29. 

part  played  by  the  wandering  cells, 
29. 

spindle-cell  growth  closing  the  ves- 
sel, 29. 

experiments  with  pieces  of  lung, 
29. 
Senn. 

the  thrombus  accidental,  does  not 
undergo  organization  and  takes 
no  part  in  obliteration  of  the 
vessel,  33. 

the  extent  of  traumatism  the  most 
important  factor  in  the  forma- 
tion of  the  thrombus,  141. 
Separation  of  ends  of  the  vessel  (see 

opening). 
Sepsis. 

septic  wounds  do  not  necessarily 
produce  an  extensive  throm- 
bus, 108. 

influence  of  antiseptics  on  forma- 
tion of  thrombus,  140,  141. 
Severinus. 

the  first  to  tie  the  femoral  artery 
at  Poupart's  lig-ament,  8. 
Shakespeare. 

derives  new  formation  from  the  en- 
dothelium and  subjacent  cellu- 
lar elements  of  the  intima,  31. 

fibrinous  and  plastic  clots,  31. 

vascularization,  31. 

endothelium,  the  origin  of  white 
blood  corpuscles,  31. 

formation  of  the  blood  clot,  31. 

confirms  Bryant's  description  of 
action  of  torsion,  36. 

modified  ligature,  36. 

experiments  on  acupressure  and 
acutorsion,  38. 

inferior  to  ligature,  39. 

minute  anatomy  of  the  ai'teries,  45. 
Sharp. 

use  of  the  ligature,  9. 
Sheath. 

Savony  advises  opening  the  sheath 
of  the  vessel  with  the  knife, 
34. 
Sickle-shaped  needle,  Ferri,  6. 
Simon. 

ruptures  in  the  arteries,  32. 

vise  of  metallic  ligatures,  42. 
Simpson. 

the  ligature  one  of  the  first  obsta- 
cles to  healing  by  first  inten- 
tion, 37. 

use  of  animal  and  metallic  liga- 
tures, 37. 

substitution  of  acupressure,  37. 
Sinus-like  degenei'ation,  16. 


l82 


The  Ligature  of  Arteries. 


Spiadle  cells,  18. 

ramification  of  spindle  cells,  25. 
spindle-shaped  cells  seen,  28,  54,  64, 

67,  73,  29,  102,  108,  142. 
appearance  in  third  stage,  146. 
Staflf-shaped  nuclei,  147. 
Stellate  cells,  16,  54. 
Stilling. 

result  of  his  investigations,  13. 
divides  the  process  of  repair  into 
three  periods,  13. 
Strieker. 

subdivision  of  the  intercellular  sub- 
stance, 20. 
Stump. 

see  amputation. 
Styptics. 

use  advised  by  Galenus,  3. 
"Roj^al  Styptic,"  8. 
Tagaliacozzi,  8. 
Subcutaneous  division  of  artery,  11. 
Susrutas,  first  recorded  use  of  ligature, 

1. 
Syphilis. 

cells  in  sj^philitic  arteries,  24. 
changes  in  the  cerebral  arterj'  in 

syphilis,  26. 
thickening  of  external  coat,  28. 
SzLiman. 

organization  of  the  thrombus,  21. 
changes  found  in  acupressure,  21. 
agrees  with  Weber,  22. 
coagulation  of  the  blood  due  to  in- 
juries of  the  intima,  44. 
Tagaliacozzi. 

used  cauteiy  and  styptics,  8. 
Tagault. 

use  of  ligature,  7. 
Tait. 

union  by  fii"st  intention,  21. 
Thiersch. 

proliferating    vessel  —  epithelium, 
20.  [20. 

vascularization  of    the  thrombus, 
Third  stage  of  repair,  139. 

absorption    of    provisional  tissues 

and  final  cicatrization,  139. 
description  of  third  stage,  146. 
Thoma. 

observations  on  a  formation  of  con- 
nective tissues  in  the  deeper 
layers  of  the  intima,  32. 
minute  anatomy  of  arteries,  46. 
description    of    the    anatomy  and 
changes  in  the  ductus  arterio- 
sus, 111. 
of  the  umbilical  (hypogastric)  ar- 
tery, 113,  129. 
Thrombus. 

agency  of  the  thrombus  in  checking 

hemorrhage,  9. 
organization  of  the  thrombus,  10, 
12,  14,  16,  17,  19,  21,  47. 


Thrombus. 

vasculai-ization,  15.  16,  20,  24,  62. 

description  by  Pouteau,  10. 

Jones,  11. 

Ribes,  Bouillaud  and  others,  12. 

elimination  of  the  thrombus,  12. 

changes  in  the  thrombus,  14. 

not  necessary  for  closure  of  vessel, 
15.  [16. 

white  corpuscles  in  the  thrombus, 

the  most  important  factor  in  sup- 
pression of  hemorrhage,  21. 

canalization  of  the  thrombus,  22. 

thrombus  reaching  to  first  collate- 
ral branch,  25. 

absence  of  thrombosis  with  strict 
asepsis,  43. 

development  of  the  white  throm- 
bus, 43. 

white  and  mixed  thrombi,  43. 

summary  of  views  on  formation  of 
thrombus,  43.  [50. 

new  growth  in  proximal  thrombus, 

infiltration  by  granulations,  66. 

formed  in  femoral  after  amputa- 
tion, 99. 

size  dependent  on  proximity  of 
branch,  100. 

stratification  of  thrombus  only 
when  thrombus  has  formed 
slowly,  107. 

attachment  to  walls  of  vessel,  109. 

size  and  appearance  of  thrombus, 
139. 

influence  of  antiseptics,  140,  141. 

thrombus  never  entirely  absent, 
141. 

formation  of  thrombus  in  case  of 
fortj^-two  days,  126. 

rapidity  of  formation,  141. 

infiltration  by  granulation  tissue, 
145. 

a  medium  for  deposit  of  granula- 
tion tissue,  145. 

variations  in  size,  150. 

Baumgarten  maintains  that  an 
artery  can  be  tied  without  for- 
mation of  thrombus,  141. 

the  extent  of  traumatism  the  most 
important  factor  in  the  pro- 
duction of  the  thrombus,  141. 

the  thrombus  accidental,  does  not 
vindergo  organization  and  take 
part  in  the  obliteration  of  the 
vessel,  33. 

septic  wounds   do  not  necessarily 
produce   an   extensive  throm- 
bus, 108. 
Torsion. 

used  in  time  of  Oribasius,  5. 

employed  in  middle  ages  and  by 
French  surgeons  of  present 
century,  35.  j 


Index, 


183 


Torsion. 

Amvissat  the  first  to  communicate 
a  paper  on  torsion,  35. 

metliod  employed  by  Velpeau,  35. 

comparison  with  the  ligature  and 
acupressure,  36. 

effect  of  torsion,  35. 

paper  by  Costello,  35. 

Galenus,  3. 

torsion  as  substitute  for  ligature, 
152. 

Rufus  of  Ephesus  and  Heliodorus 
familiar  with  torsion,  8. 
Tourniquet. 

invented  by  Morel,  8. 
Transfixion  of  vessel,  6. 
TsehausofC. 

investigations  on  brachial  artery  of 
a  stump,  23. 

thrombus  takes  no  part  in  the  or- 
ganization, 22. 

cicatrization  accomplished  by  con- 
nective tissue  elements,  22. 
Ulceration  of  the  ligature,  79. 
Umbilical  cord. 

ligature  of  umbilical  cord,  1. 

action  of  the  umbilical  vessels,  10, 
15,  32. 

umbilical  (hypogastric)  artery,  113. 

elastic  lamina,  113. 

contraction  of  the  media,  113. 

hyaline  connective  tissue,  113. 

Baumgarten's  description  of  vimbi- 
lical  artery  in  the  adult,  113. 

process  of  obliteration,  113. 

experiments  on  the  foetal  vessels, 
114,  129. 

peculiarities  in  anatomical  struc- 
ture, 124. 

earliest  changes,  130. 

hyaline  degeneration,  131,  135. 

conversion  into  cord,  131. 

growth  into  thrombus,  132. 

contraction  of  outer  walls,  133. 

development  of  new  tissue,  132. 

permanence  of  the  umbilical  artery, 
129. 

muscular  character  of  obliterating 
tissue,  134. 

thrombus  found  in  new-born  child, 
134. 

lumen  soon  obliterated,  135. 

thrombus  not  of  traumatic  origin, 
135. 

presence  of  large  amount  of  longi- 
tudinal muscular  fibre,  135. 

absence  of  well  defined  outline  to 
inner  wall  of  media,  135. 

contraction  at  time  of  birth,  135. 

permanence  of    vessel    disproved, 
135. 

growth  of  tissue  at  second  month, 
136. 


Umbilical  cord. 

contraction  of  coats,  136. 
gTOwth  of  young  cells,  136. 
granulation-like  masses,  136. 
condition  at  adult  age,  136. 
summary  of  changes   since  birth, 

136. 
newly  formed  tissue  of  muscular 

character,  136. 
not  developed  from  intima,  136. 
extreme  end  of  the  vessel  not  closed 

by  fibrinous  tissue,  137. 
experiments  on  the  monkey,  137. 
calcification  of  the  walls  seen  in 
tibial  and  femoral,  not  observed 
in  hypogastric  artery  of  adults, 
but  found  in  ligamentum  ar- 
te riosum,  137. 
resemblance  to  changes  in  arteries 

after  amputation,  137. 
formation  of  new  muscular  fibre, 

137. 
summary  of  results  after  closure, 
151. 
Unfolding  of  ends  of  vessel,  80. 

see  opening. 
Uterus. 

formation  of  muscular  cells  in  walls 
of  uterus,  148. 
"ValetaPatin,"9. 
Van  Soligen. 

modification  of  the  forceps,  8. 
Vasa  vasorum. 

action  in  causing  growth  of  tissue, 
10,  11.  [46. 

presence  in  outer  and  middle  coats, 
Vascular  spaces. 

reg'arded  by  Stilling  as  sinuses,  13. 
Vascularization. 

of  thrombus,  15,  16,  20,  24,  62. 
Veins. 

difference    between    arteries    and 
veins,  1. 
Velpeau. 

experiments  upon  animals,  35. 
pressure  sufficient  to  prevent  bleed- 
ing, 35. 
circulation  not  under  control  of  the 

heart,  35. 
method  of  performing  torsion,  35. 
Verneuil. 

narrowing-  of  vessels,  33. 
contraction  of  the  media,  compen- 
satory arteritis  and  atrophy  of 
the  muscular  coat,  33. 
shape  and  size  of  the  cicatrix,  33. 
Vigo,  de. 

accredited  with  the  disco veiy  of 
acupressure,  6. 
Vinegar  used  to  arrest  hemorrhage,  2. 
Virchow. 

omnis  cellula  e  cellula,  16. 
action  of  the  white  corpuscles,  16. 


1 84 


TJie  Ligature  of  Arteries. 


Virchow. 

stellate  cells,  16. 

sinus-like  degeneration,  16. 

vascularization  of   the  thrombus, 
16. 

slowing  of  the  blood -current  as  a 
factor  in  coagulation,  42. 

axiom     concerning     inflammation 
and  thrombosis,  44. 
Waldeyer. 

action  of  endothelium  in  pi-oducing 
connective  tissue,  19. 

organization  of  the  thrombus,  19. 
Waller. 

observations  of  passage  of  white 
corpuscles,  20. 
Walsham. 

placed  double  ligature  on  the  ves- 
sel, employing  carbolized  liga- 
tures, 34. 
Walther,  von. 

accepts  Hunter's  views,  13. 

believes  that  the  vessel-walls  com- 
bine with  the  clot  to  form  a 
cicatricial  tissue,  13. 
Wandering  cells,  20,  21.  [31,  47. 

action  of  wandering  cells,  26,  29, 

their  passage  through  the  walls, 
49,  56,  64. 

cells  infiltrating  walls,  109. 

presence  of  wandering  cells,  142. 

in  posterior  tibial  alter  three  weeks, 
104. 


Warren  Anatomical  Museum, 
specimens  from,  83,  85,  91. 
Weber. 

confirms  Vii-chow's  views,  17. 
oi'ganization  of  the  thrombus,  17. 
action  of  white  corpuscles,  17. 
stellate  net-work,  18. 
White. 

opinion  that  clot  prevents  closure 
of  the  artery,  10. 
Winiwarter. 

endarteritis,  24. 

changes  observed  in  the  arteries 

and  veins,  26,  37. 
formation  of  lamiuce,  27. 
minute  anatomy  of  the  arteries,  45. 
Wiseman. 

use  of  the  "  Royal  Styptic,"  or  the 
cautery,  8. 
Wyeth. 

process  observed  in  traumatic  ar- 
teries, 28. 
thinks  division  of  the  inner  and 
middle  coats  unnecessary,  33. 
Zahn. 

experiments  on  rabbits,  32. 
development  of  the  white  throm- 
bus, 43. 
Zwicky. 

repeats  experiments  of  Jones  and 

Stilling,  14. 
formation  of  vessels  in  the  throm- 
bus, 15. 


M 


1  T 


^1 


7 'I  ■■>    v)|\fl 


V'ck 


\--A\  \^ 


:<^€ 


ff    m 


fefe^'^'//'''''  \*  'A\^:^%^ffi 


M 


^^B» 


2  T 


>°E!/f»"/5^ 


-  °"^°°°°%o:v 


'?%° 


•■y>^;< 


;'Ooo    o^' 


-^i^?'^ 


L 


••SjSlv''il>'"'  '  A  kr^^.vjl-i;::/.:*" 


ilMdlSp'  •        '''fc^"- 


c/^  \4^arren,  De/, 


MP{^Uiri^:Q/,Scv/p. 


W/ii///|^7 


3 

III 


JCMrren,  M. 


/ 


B 


iU 


^C.mrm  Al 


A^P(^a/r/Cf,Scm; 


IV" 


11 


13 


J'.Cm/ren  M. 


.ff./"'  iJidricy.ucuip. 


V 


@  ^  &  ^^^ 

^^^^^.  \[\_ 


'  C^Vfrren.  J^el 


J/./?  OfJ^qcy.  Sculp. 


vii 


^ 


J    'SI 


4^'    S 


Vii 


"%^, 


'^4:J    '\/#j      18 


'/M 


// 


'7/  ^'^■"'^   ^' 


A-^ 


Jf:mm/i,Ai 


j^  P  ^ll//^C^  Scii.^i 


JC.Wdrrm,M. 


j?'/^  (^u'jycy.Scu/p. 


M^^ 


t' 


m 


c 


.y.CMrren,  JM 


//./i'{?uL'?cy.S(:u^p. 


\  r 


^'¥!l! 


-V 


.r" 


\/ 


n 


0mmm 


c 

JC.  IVarren,  J) el 


//k^i''"i"rAii\  '  ,   /A, 


A^J/  <^'U^r^cy^  '^cdp. 


^2 


JCWdrrm.  I/el 


J{J^  (^w.r?cj,^ci>:ii 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 
This  book  is  DUE  on  the  last  date  stamped  below. 


WArfiJ  isoo 


A  1  3-'80 
RETURMD  TO  UCSB 

AUGo    1981 

AlJf^^  2  6  REC*a 
AUG  2  8  REC'O 


Form  L9-30m-7,'56(C824s4)444 


Hflffi  LIBRARY 


'.-    '^^WTv'Wk^'WA. 


I 


It 


>-'  ■;'■ 


/  '.  :  -,^-U:- 

. -iv.^^- ■•^^^^ii 

■'-:-,,.,  .M 

-■:■■?■ --JB 

■:..;^c^^.,^ 

i     '"' 

.•■:::.-^-::ii?5- 

i 

.:-:-:''/^!^ 

"^                      '     ■  ;. 

'^"•■'--'■■'-''=^tt 

^'' '      ".^'•- 

■■-■■i'-'''f -^^IB 

''^^^^^^^1 

■-^..j 


*-i* 

■■  ^ 

■% 

M 

^v 

? 

W  !,V 

»i  , 

V-- 

:;: 

'  ',■''• 

Vj'       ' 

'-     Jl 

«■■ 

■'i' 

-J- 

■-. 

■/■ 

r'" 

'  ".*•■' 

^'r 

.•.^vv-?^ 


.^.;j 


